LTSS UM RN

Job Description

Job Description

Utilization Review Nurse (RN) - Managed Long-Term Care (MLTC) (MUST LIVE IN TRI STATE AND HAVE NY LICENSE)

Position: Utilization Review Nurse (Registered Nurse)

Location: 100% Remote (Candidates must hold an active NY RN license)

Schedule: Monday - Friday, 9:00 AM - 5:00 PM (35 hours/week)

Employment Type: Full-Time

About the Role

We are seeking a self-motivated, clinically astute Utilization Review Nurse (RN) to join our Managed Care Organization (MCO). In this critical role, you will evaluate member care plans and service requests to determine medical necessity, ensuring high-quality, cost-effective healthcare delivery. Working cross-functionally with Medical Directors, Physician Peer Reviewers, and clinical colleagues, you will conduct prospective, concurrent, and retrospective reviews with a primary focus on long-term care services and durable medical equipment.

Key Selling Points for Candidates

• 100% Remote Flexibility & Work-Life Balance

  • True Work-From-Home Autonomy: Enjoy a dedicated 100% remote work structure that eliminates daily commutes and provides greater control over your daily schedule.

  • Generous Time-Off Package: Benefit from comprehensive paid time off, including competitive PTO, 10 paid holidays, dedicated personal days, and paid family leave to ensure you can recharge.

  • Predictable Schedule: Work a balanced 35-hour work week (Monday-Friday, 9:00 AM-5:00 PM) with no nights, weekends, or mandatory on-call shifts.

• Meaningful Impact in Community-Based Care

  • Advocate for Independent Living: Use your clinical expertise to directly impact members' quality of life, ensuring they receive the exact care, equipment (DME), and personal support (PCA) needed to safely maintain their independence at home.

  • Evidence-Based Patient Advocacy: Serve as an essential bridge between care plans and clinical necessity, ensuring members receive timely, high-quality, and cost-effective services without unnecessary administrative delays.

• Professional Development & Clinical Upskilling

  • Master Industry-Standard Guidelines: Gain hands-on expertise and continuous exposure to leading clinical decision-support tools such as InterQual and Milliman Care Guidelines (MCG).

  • Continuing Education Opportunities: Expand your credentials with built-in education reimbursement and opportunities to advance into senior clinical management, quality improvement, or appeal review roles.

• Collaborative & Supportive Interdisciplinary Environment

  • Direct Physician Collaboration: Work side-by-side with Physician Peer Reviewers and Medical Directors in a supportive environment where your clinical judgment and input are trusted and valued.

  • Team-Centric Culture: Join a mission-driven organization that values collaborative problem-solving, structured mentorship, and cross-functional teamwork over working in isolation.

Key Responsibilities

• Clinical Reviews & Assessments: Conduct prospective, concurrent, and retrospective utilization management reviews using evidence-based clinical criteria to determine medical necessity, appropriateness of care, and benefit coverage.

• Peer Collaboration: Partner directly with Physician Peer Reviewers and Medical Directors to review complex cases, support sound coverage decisions, and proactively mitigate potential care delays or coverage denials.

• Care Coordination & Advocacy: Intervene proactively in care planning to reduce administrative delays, address authorization issues, and ensure seamless delivery of long-term support services.

• Compliance & Documentation: Maintain complete, accurate, and timely documentation within the electronic health record (EHR) system in accordance with regulatory standards and internal organizational policies.

• Appeals & Quality Support: Follow up on denial outcomes and internal appeals in a timely manner while contributing to ongoing organizational Quality and Performance Improvement (QPI) initiatives.

Qualifications

Required:

• Licensure: Active, unrestricted Registered Nurse (RN) license in good standing in the State of New York.

• Education: Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing (ASN) from an accredited institution.

• Experience: Minimum of 2+ years of Utilization Review / Utilization Management experience within a Managed Care Organization (MCO) or Health Plan.

• Specialized Knowledge: Direct experience in Managed Long-Term Care (MLTC), including authorization workflows for:

  • Personal Care Aide (PCA) services

  • Durable Medical Equipment (DME)

  • Personal Emergency Response Systems (PERS)

  • Social Adult Day Care (SADC)

• Regulatory Compliance: Strong working knowledge of Medicare and/or Medicaid coverage guidelines, benefit limitations, and state healthcare regulations.

Preferred:

• Advanced Degree: Master of Science in Nursing (MSN) or a master's degree in a related healthcare administration field.

• Certifications: Certified Case Manager (CCM), Health Utilization Management certification, or working knowledge of URAC accreditation standards.

• Clinical Decision Support Tools: Hands-on experience applying InterQual, Milliman Care Guidelines (MCG), or equivalent evidence-based clinical decision tools.

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Company Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?

Company Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.\r\rOur commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?