Utilization Review Nurse LTSS Contract-to-Perm - REMOTE
Utilization Review Nurse LTSS Contract-to-Perm - REMOTE
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
Job Description
Utilization Review Nurse LTSS (ContracttoPerm)
Location: Remote however Candidates must reside in one of the following states: AZ FL GA ID IA KY MI NE NM NY OH TX UT WA or WI
Schedule: MondayFriday 8:00 AM 4:30 or 5:00 PM EST
Pay Rate: $42.00 per hour Full Health Benefit Plan Offered
ContracttoHire Opportunity
Join a MissionDriven Managed Care Organization
This is your chance to join one of the nations most respected Managed Care Organizations known for its commitment to delivering highquality costeffective healthcare to underserved populations. With a culture of compassion and innovation this organization is recognized for prioritizing patient outcomes and creating opportunities for professional growth across the country.
Position Overview
The Utilization Review Nurse (LTSS) supports the Utilization Management team and is responsible for reviewing longterm services and supports (LTSS) provider requests primarily by evaluating clinical documentation to ensure appropriateness of care cost efficiency and compliance with state and federal regulations. The role plays a critical part in ensuring members receive the right care at the right time particularly under Virginia Medicaid guidelines.
Key Responsibilities
Review LTSS provider service requests against case management documentation
Conduct prior authorization and concurrent reviews in accordance with clinical guidelines and organizational policy
Complete reviews within turnaround time (TAT) expectations
Identify member eligibility applicable benefits and appropriate levels of care
Collaborate with internal care teams including Behavioral Health and LongTerm Care
Refer cases to medical directors when needed for clinical decisionmaking
Participate in staff meetings and crossfunctional collaboration
Provide mentorship to new team members as assigned
Maintain documentation standards compliance and productivity benchmarks
Ensure HIPAA and regulatory compliance at all times
Requirements
Active unrestricted RN license in Virginia or Compact State (required)
Completion of an accredited Registered Nursing program
02 years of clinical practice experience (hospital utilization management or case management preferred)
Experience with LTSS highly preferred
Familiarity with Virginia Medicaid is a strong plus
Knowledge of InterQual Milliman or other medical necessity tools
Experience with NCQA standards and utilization review policies
Comfortable working independently in a fully remote environment
Strong written/verbal communication and organizational skills
Proficient with Microsoft Office products; experience with clinical systems a plus
Work Environment & Schedule
100 Remote
Candidates must be available to work EST business hours
This is a contracttopermanent position with the opportunity to grow within a missiondriven team that values clinical excellence accountability and member advocacy.
Employment Type
Contract
