[Hiring] Contingent Utilization Review / Long-Term Services & Supports Review Nurse @MICHIGAN PEER REVIEW ORGANIZATION

Role Description

iMPROve Health is seeking an experienced Michigan-licensed Registered Nurse (RN) to join our team as a Contingent Utilization Review / Long-Term Services & Supports (UR/LTSS) Review Nurse. This fully remote position supports Michigan Medicaid programs by conducting Nursing Facility Level of Care (LOC) reviews and Home Help quality review assessments.

This role is ideal for experienced nurses with both Utilization Review/Utilization Management (UR/UM) and Long-Term Services & Supports (LTSS)/Long-Term Care experience who are looking for flexible, contingent work while remaining engaged in meaningful clinical practice.

• Evaluate medical records and conduct telephonic and virtual assessments.
• Apply established clinical and regulatory criteria.
• Ensure timely, accurate review determinations.
• Participate in administrative hearings and appeals when necessary.
• Maintain regular availability of at least 4–8 hours per week.
• Work performed during normal business hours; occasional evening, weekend, or holiday work may be required.

Qualifications

• 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.
• 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.
• Experience with electronic health records, secure web-based portals, and Microsoft Office applications.
• Ability to work independently in a remote environment while consistently meeting productivity, quality, and timeliness expectations.

Requirements

• 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.
• Maintain current knowledge of contractual requirements, Medicaid regulations, and applicable clinical guidelines.
• Comply with all applicable HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements.
• Participate in required training, calibration, and quality assurance activities.
• Perform other duties as assigned.

Benefits

• Fully remote, contingent position.
• Most work is completed during normal business hours.
• Occasional evening, weekend, or holiday work may be required to meet operational deadlines.