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Registered Nurse – Contingent
iMPROve Health. Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards .
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 managing review processes and documentation while adhering to Medicaid regulations and organizational policies.
Highest-signal resume keywords
Active Michigan Registered Nurse (RN) LicenseUtilization Review (UR) ExperienceLong-Term Care/LTSS ExperienceClinical Assessment SkillsExperience with Electronic Health Records
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewLong-Term Services & Supports (LTSS)Clinical AssessmentCritical ThinkingAnalytical SkillsDocumentation SkillsMedicaid RegulationsNursing Facility Level of Care (LOC) DeterminationsEvidence-Based Clinical CriteriaQuality Assurance
Soft Skills
Strong Written CommunicationVerbal CommunicationInterpersonal CommunicationAbility to Work IndependentlyTime Management
Tools & Technologies
Microsoft TeamsMicrosoft OfficeElectronic Health RecordsSecure Web-Based Portals
Certifications & Qualifications
Active Michigan Registered Nurse (RN) License
Industry Keywords
Utilization Management (UM)MedicareHIPAA ComplianceFISMA ComplianceURAC ComplianceCMS Compliance
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 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 and professionally 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
- At least 4–8 hours of regular availability per week
- Occasional evening, weekend, or holiday availability may be required
Benefits
Comp & perks- 100% remote work from anywhere in the United States
- Flexible, contingent work schedule
- Opportunities for additional hours based on program needs
- Meaningful clinical practice supporting healthcare quality and outcomes
- Required training, calibration, and quality assurance activities