Contingent UR/LTSS Registered Nurse

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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 using established LTSS criteria. • Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases. • Conduct virtual Home Help assessments using Microsoft Teams for beneficiaries selected by the Michigan Department of Health and Human Services (MDHHS). • 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. • Utilize a case management approach from case assignment through completion while meeting established turnaround times. • Document review findings accurately, thoroughly, and professionally within secure electronic systems and state portals. • Communicate effectively 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.

🎯 Requirements

• Active, unrestricted Michigan Registered Nurse (RN) license required. • Long-Term Care/LTSS experience is required. • Utilization Review (UR) and/or Utilization Management (UM) experience is required. • Minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS. • Bachelor's degree in nursing preferred. Equivalent experience may be considered in lieu of a bachelor's degree. • 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.

🏖️ Benefits

• Flexible work arrangements • Professional development