REMOTE LTSS Nurse (NY License) - 257198

LTSS Utilization Review Nurse

Job Summary

We are seeking a self-motivated and clinically focused LTSS Utilization Review Nurse to join our Managed Care Organization. This role is responsible for evaluating member care plans, services, and medical requests to determine
medical necessity, appropriateness, and coverage while supporting high-quality, cost-effective healthcare delivery.

The LTSS Utilization Review Nurse will collaborate closely with Medical Directors, Physician Peer Reviewers, and clinical teams to conduct
prospective, concurrent, and retrospective reviews, with a focus on
Long-Term Services and Supports (LTSS) and durable medical equipment (DME).

Key Responsibilities


- Conduct prospective, concurrent, and retrospective utilization reviews using evidence-based clinical criteria to determine medical necessity and coverage appropriateness.
- Evaluate member care plans, clinical documentation, LTSS services, and DME requests.
- Collaborate with Physician Peer Reviewers and Medical Directors on complex cases and coverage determinations.
- Proactively identify and address authorization issues, administrative barriers, and potential delays in care.
- Support appropriate and timely delivery of medically necessary long-term support services.
- Maintain accurate, thorough, and timely documentation in the electronic health record (EHR) in accordance with regulatory requirements and organizational policies.
- Follow up on denials, reconsiderations, and internal appeals within required timeframes.
- Participate in Quality and Performance Improvement (QPI) initiatives and support continuous improvement of utilization management processes.
- Apply sound clinical judgment while balancing quality of care, member needs, regulatory requirements, and cost-effective healthcare delivery.


Qualifications


- Active, unrestricted New York State RN nursing license required.
- Must reside in NY, NJ, or CT.
- Clinical nursing experience, preferably in LTSS, utilization management, utilization review, case management, long-term care, managed care, or health plan operations.
- Experience reviewing medical necessity and applying evidence-based clinical criteria preferred.
- Strong understanding of healthcare authorization, coverage determination, and regulatory requirements.
- Excellent clinical judgment, communication, documentation, and organizational skills.
- Ability to work independently while collaborating effectively with physicians, Medical Directors, and multidisciplinary clinical teams.
- Strong computer skills and experience working with electronic health records and healthcare systems.


Why Join Us?


- Make a meaningful impact on member care and healthcare outcomes.
- Use your clinical expertise in a specialized LTSS and Utilization Management environment.
- Collaborate with experienced clinical and physician leadership.
- Support members in accessing appropriate, medically necessary long-term services and supports.
- Join a team focused on quality, member advocacy, regulatory compliance, and continuous improvement.
- Opportunities for professional growth within Managed Care and Utilization Management.