Job Description

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.

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