Contingent Registered Nurse, UR/LTSS

iMPROve Health

. Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards .

Posted 9/18/2026part-timeRemote • Michigan • United StatesMid-LevelSenior💰 $36 - $42 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Review and Long-Term Services & Supports, with a strong focus on clinical assessment, regulatory compliance, and effective communication with stakeholders. Proficient in managing cases and documentation within electronic systems while adhering to Medicaid regulations and clinical guidelines.

Highest-signal resume keywords

Active Michigan Registered Nurse (RN) LicenseUtilization Review (UR) ExperienceLong-Term Care/LTSS ExperienceClinical Assessment SkillsMedicaid Regulations Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewLong-Term Services & Supports (LTSS)Clinical AssessmentDocumentation SkillsCritical ThinkingAnalytical SkillsNursing Facility Level of Care (LOC) DeterminationsRegulatory ComplianceEvidence-Based Clinical CriteriaQuality Review

Soft Skills

Interpersonal CommunicationVerbal CommunicationWritten CommunicationAnalytical ThinkingIndependent Work

Tools & Technologies

Electronic Health RecordsMicrosoft TeamsMicrosoft OfficeSecure Web-Based PortalsMicrosoft OutlookMicrosoft WordMicrosoft Excel

Certifications & Qualifications

Active Michigan Registered Nurse (RN) License

Industry Keywords

MedicaidMedicareUtilization Management (UM)HIPAA ComplianceFISMA ComplianceURAC StandardsCMS RegulationsClinical GuidelinesHome Help AssessmentsAdministrative Hearings

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
Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases
Conduct virtual Home Help assessments using Microsoft Teams
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
Manage cases from assignment through completion while meeting established turnaround times
Document review findings accurately within secure electronic systems and state portals
Communicate 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 HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements
Participate in required training, calibration, and quality assurance activities
Perform other duties as assigned

Requirements

What you’ll need

Active, unrestricted Michigan Registered Nurse (RN) license required
Long-Term Care/LTSS experience required
Utilization Review (UR) and/or Utilization Management (UM) experience required
Minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS
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, 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
Minimum availability of 4–8 hours per week required
Occasional evening, weekend, or holiday work may be required

Benefits

Comp & perks

100% remote work
Flexible contingent work schedule
Opportunities for additional hours based on program needs
Meaningful clinical practice supporting healthcare quality and outcomes
Participation in required training, calibration, and quality assurance activities