Contingent Registered Nurse, UR/LTSS

🔥 0 minutes ago

🚗 Michigan – Remote

🚗 Michigan – Remote

💵 $36 - $42 / hour

⏱ Part Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 3%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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iMPROve Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1984

🏥 Healthcare

⚕️ Healthcare Insurance

💼 Consulting

Healthcare • Healthcare Insurance • Consulting

iMPROve Health is a national, fully-remote organization that specializes in healthcare quality improvement and review services. For about 40 years it has provided independent medical review, utilization review, Medicare and Medicaid program support, research methodologies, data analysis, outreach strategies, and dispute resolution (including Independent Dispute Resolution under the No Surprises Act). The organization is URAC-accredited for more than 20 years, is a certified independent dispute resolution entity, and delivers QI solutions, peer review, and related consulting services to healthcare stakeholders across multiple states.

📋 Description

• Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards • Conduct telephonic Nursing Facility Level of Care (LOC) reviews for Michigan Medicaid beneficiaries • Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases • Conduct virtual Home Help assessments using Microsoft Teams • Review medical records, assessments, care plans, and supporting clinical documentation to determine eligibility and medical necessity • Apply evidence-based clinical criteria and state regulations to support review determinations • Manage cases from assignment through completion while meeting established turnaround times • Document review findings accurately within secure electronic systems and state portals • Communicate with providers, beneficiaries, and internal staff regarding review findings and requests for additional information • Participate in administrative hearings and appeals to represent review determinations when required • Maintain current knowledge of contractual requirements, Medicaid regulations, and applicable clinical guidelines • Comply with HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements • Participate in required training, calibration, and quality assurance activities • Perform other duties as assigned

🎯 Requirements

• Active, unrestricted Michigan Registered Nurse (RN) license required • Long-Term Care/LTSS experience required • Utilization Review (UR) and/or Utilization Management (UM) experience required • Minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS • Equivalent experience may be considered in lieu of a bachelor's degree • Experience working with Michigan Medicaid or other state-based healthcare contracts preferred • Strong knowledge of Medicare, Medicaid, Long-Term Services & Supports (LTSS), Nursing Facility Level of Care (LOC) determinations, and long-term care regulations preferred • Excellent clinical assessment, critical thinking, analytical, and documentation skills • Strong written, verbal, and interpersonal communication skills, including the ability to explain and defend clinical review determinations • Experience with electronic health records, secure web-based portals, and Microsoft Office applications, including Outlook, Teams, Word, and Excel • Ability to work independently in a remote environment while consistently meeting productivity, quality, and timeliness expectations • Minimum availability of 4–8 hours per week required • Occasional evening, weekend, or holiday work may be required

🏖️ Benefits

• 100% remote work • Flexible contingent work schedule • Opportunities for additional hours based on program needs • Meaningful clinical practice supporting healthcare quality and outcomes • Participation in required training, calibration, and quality assurance activities