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Contingent UR/LTSS Registered Nurse
iMPROve HealthContingent Registered Nurse performing utilization reviews for Michigan Medicaid programs while working remotely. Evaluating cases and ensuring compliance with established criteria and regulations.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Long-Term Services & Supports (LTSS) with a strong focus on clinical assessment, regulatory compliance, and effective communication. Proficient in utilizing electronic health records and secure systems to document and manage review processes efficiently.
Highest-signal resume keywords
Michigan Registered Nurse (RN) LicenseUtilization Review (UR) ExperienceLong-Term Care/LTSS ExperienceClinical Assessment SkillsElectronic Health Records Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Utilization ReviewLong-Term Services & Supports (LTSS)Clinical AssessmentCritical ThinkingAnalytical SkillsDocumentation SkillsNursing Facility Level of Care (LOC) DeterminationsRegulatory ComplianceEvidence-Based Clinical CriteriaQuality Review
Soft Skills
Effective CommunicationInterpersonal SkillsIndependent WorkProblem-SolvingTime Management
Tools & Technologies
Microsoft TeamsMicrosoft OfficeElectronic Health RecordsSecure Web-Based Portals
Certifications & Qualifications
Active Michigan Registered Nurse (RN) License
Industry Keywords
MedicareMedicaidLong-Term Care RegulationsHome Help AssessmentsTelephonic Reviews
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- Flexible work arrangements
- Professional development