iMPROve Health

Nurse

• 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.

Contingent UR/LTSS Registered Nurse