Offer summary

Qualifications:

Active, unrestricted RN license in Virginia or a Compact State is required., Completion of an accredited Registered Nursing program is necessary., 0–2 years of clinical practice experience, preferably in hospital, utilization management, or case management., Familiarity with Virginia Medicaid and experience with LTSS is highly preferred..

Key responsabilities:

Review LTSS provider service requests against case management documentation.

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

Collaborate with internal care teams and refer cases to medical directors when needed.

Maintain documentation standards and ensure HIPAA and regulatory compliance at all times.

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.

Required profile