Utilization Review Nurse LTSS (Contract-to-Perm) - REMOTE

Utilization Review Nurse – LTSS (Contract-to-Perm)

Location: Remote however Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY, OH, TX, UT, WA, or WI

Schedule: Monday–Friday 8:00 AM – 4:30 or 5:00 PM EST

Pay Rate: $42.00 per hour + Full Health Benefit Plan Offered

Contract-to-Hire Opportunity

Join a Mission-Driven Managed Care Organization

This is your chance to join one of the nation’s most respected Managed Care Organizations, known for its commitment to delivering high-quality, cost-effective healthcare to underserved populations. With a culture of compassion and innovation, this organization is recognized for prioritizing patient outcomes and creating opportunities for professional growth across the country.

Position Overview

The Utilization Review Nurse (LTSS) supports the Utilization Management team and is responsible for reviewing long-term services and supports (LTSS) provider requests, primarily by evaluating clinical documentation to ensure appropriateness of care, cost efficiency, and compliance with state and federal regulations. The role plays a critical part in ensuring members receive the right care at the right time, particularly under Virginia Medicaid guidelines.

Key Responsibilities

Review LTSS provider service requests against case management documentation

Conduct prior authorization and concurrent reviews in accordance with clinical guidelines and organizational policy

Complete reviews within turnaround time (TAT) expectations

Identify member eligibility, applicable benefits, and appropriate levels of care

Collaborate with internal care teams, including Behavioral Health and Long-Term Care

Refer cases to medical directors when needed for clinical decision-making

Participate in staff meetings and cross-functional collaboration

Provide mentorship to new team members as assigned

Maintain documentation standards, compliance, and productivity benchmarks

Ensure HIPAA and regulatory compliance at all times

Requirements

Active, unrestricted RN license in Virginia or Compact State (required)

Completion of an accredited Registered Nursing program

0–2 years of clinical practice experience (hospital, utilization management, or case management preferred)

Experience with LTSS highly preferred

Familiarity with Virginia Medicaid is a strong plus

Knowledge of InterQual, Milliman, or other medical necessity tools

Experience with NCQA standards and utilization review policies

Comfortable working independently in a fully remote environment

Strong written/verbal communication and organizational skills

Proficient with Microsoft Office products; experience with clinical systems a plus

Work Environment & Schedule

100% Remote

Candidates must be available to work EST business hours

This is a contract-to-permanent position with the opportunity to grow within a mission-driven team that values clinical excellence, accountability, and member advocacy.