LTSS UM RN

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: Inte