Utilization Review Nurse, LTSS and HCBS - Remote in Michigan

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The Utilization Management Nurse is responsible for conducting clinical reviews and authorizations for LTSS and HCBS services. This role ensures that members receive medically necessary, cost-effective, and person-centered care in the least restrictive environment. The nurse collaborates with interdisciplinary teams, care managers, and providers to support member goals and improve health outcomes. If you reside in Michigan, you will have the flexibility to work remotely* as you take on some tough challenges.

Review and process prior authorization requests for LTSS and HCBS services including Personal Care Services (PCS), Home and Environmental Modifications and others Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services. Participate in secondary reviews for complex cases, including transitions between community and institutional settings. Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the member’s service plan. Monitor utilization patterns and identify opportunities for improved care coordination and cost containment. Document all clinical decisions and communications in accordance with regulatory and organizational standards. Stay current with federal and state regulations, including 42 CFR Part 456 and CMS guidelines for HCBS and LTSS. Support quality improvement initiatives and participate in audits and compliance reviews. Participate in annual Inter-Rater Reliability testing and pass with a score of 90% or higher Appropriately identifies the need for secondary reviews or case consultations with the Medical Director Documents concise case reviews Apply relevant regulatory requirements to ensure compliance with clinical documentation. Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed. Participate in state or plan-required audits and comply with all reporting requirements by area of responsibility