Registered Nurse - Remote Work Flex

Job Description LTSS Appeals Nurse (Remote)

We are seeking a detail-oriented, self-motivated Registered Nurse to join our team as an LTSS Appeals Nurse. In this role, you will perform high-volume clinical reviews within the appeals process, evaluating complex medical records and Long-Term Services and Supports (LTSS) benefits against regulatory and medical necessity criteria.

Review and analyze clinical records, including comparative evaluations of members' two most recent assessments.

Evaluate documentation against applicable benefit, medical necessity, and regulatory standards.

Prepare concise, accurate clinical summaries and synthesized findings for the Medical Director.

Research and interpret clinical data to support appropriate appeal decisions.

Thoroughly document findings, determinations, and rationale within internal systems.

Collaborate with Medical Directors, clinical leadership, and cross-functional teams throughout the review process.

Support departmental quality and process-improvement initiatives.

Maintain strict confidentiality while adhering to all organizational policies and healthcare regulations.

Education & Licensure: ASN or BSN degree with an active, unrestricted New York Registered Nurse (NY RN) license.

Clinical Experience: Minimum 3 years of relevant nursing/healthcare experience, with dedicated experience involving Long-Term Services and Supports (LTSS).

Direct experience reviewing medical records, performing utilization review, appeals, grievances, or clinical management activities.

Strong understanding of healthcare benefits, service determinations, and medical necessity criteria.

Technical Skills: Strong computer proficiency and experience working with electronic medical record systems.

Proven ability to independently manage high daily review volumes in a remote environment.

Experience with Personal Care Aide (PCA) benefits and the Consumer Directed Personal Assistance Program (CDPAP).

Prior experience in Medicaid managed care, health plans, or managed care organizations.

In-depth knowledge of NYS healthcare regulations and managed-care requirements.

Background in preparing clinical summaries directly for Medical Directors.

Prior experience in quality management or clinical quality initiatives.

Work Location: Remote (Must be located in NY, NJ, or CT).

Shift: Flexible standard Monday-Friday business hours (e.g., 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.

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