Job Title: Utilization Management Registered Nurse (UM RN) – SNF / MLTC
Location: Remote (Must reside in NY, NJ, or CT)
Schedule: Monday – Friday, 9:00 AM – 5:00 PM
Position Type: Full-Time
Position Overview
We are seeking an experienced Utilization Management Registered Nurse (UM RN) with a strong background in Skilled Nursing Facility (SNF) operations, Medicare, and Managed Long-Term Care (MLTC). This is a 100% remote position, but candidates must reside in New York, New Jersey, or Connecticut and hold an active New York RN license.
In this role, you will evaluate clinical documentation, assess medical necessity, ensure appropriate levels of care, and align services with payer guidelines and regulatory requirements. The ideal candidate brings proven experience conducting utilization reviews within a SNF, health plan, or managed care setting, alongside strong clinical judgment and the ability to collaborate effectively across interdisciplinary teams, healthcare providers, and payers.
Key Responsibilities
- Utilization Reviews: Conduct prospective, concurrent, and retrospective reviews for SNF residents to evaluate medical necessity, appropriateness of level of care, and continued stays.
- Regulatory & Payer Alignment: Apply Medicare, MLTC, Medicaid, and managed care guidelines to all SNF service evaluations, ensuring clinical documentation supports the level of care provided.
- Care Transitions & Discharge: Monitor residents' length of stay, review admissions, transfers, and discharge plans, and identify opportunities for timely, appropriate care transitions.
- Interdisciplinary Collaboration: Work closely with physicians, nurse practitioners, social workers, case managers, therapists, and facility leadership to streamline care management.
- Payer Communication: Maintain ongoing communication with health plans and managed care organizations regarding authorizations, medical necessity reviews, and continued stay determinations.
- Quality & Appeals: Identify potential overutilization, underutilization, gaps in care, and barriers to discharge; assist with appeals, reconsiderations, and denial management as needed.
- Compliance & Documentation: Maintain precise, timely documentation in compliance with organizational and regulatory standards. Stay up to date on evolving Medicare, MLTC, Medicaid, and payer-specific guidelines.
Qualifications & Required Skills
- Licensure: Active, unrestricted New York Registered Nurse (RN) license.
- Residency: Must currently reside in New York, New Jersey, or Connecticut.
- Education: Bachelor of Science in Nursing (BSN) preferred, though equivalent experience will be considered.
- Clinical Experience: 3+ years of clinical nursing experience, preferably within a SNF, long-term care, managed care, utilization management, or case management environment.
- Domain Knowledge: Direct experience working with Medicare and MLTC populations, with a strong understanding of SNF levels of care, medical necessity, and discharge planning.
- Technical & Core Skills: Proven experience performing chart and utilization reviews, paired with strong clinical judgment, clear communication, and precise documentation habits.
- Work Style: Ability to work independently in a remote environment while engaging productively as part of an interdisciplinary team.
Preferred Qualifications
- Dedicated SNF utilization management or case management experience.
- Hands-on experience working directly with MLTC and Medicare Advantage plans.
- In-depth familiarity with Medicare Part A SNF benefits, skilled coverage criteria, authorizations, and continued stay reviews.
- Knowledge of the Minimum Data Set (MDS), care planning, clinical criteria, and payer-specific guidelines.
- Proficiency with Electronic Medical Record (EMR) systems and dedicated utilization management platforms.
- Prior experience handling appeals, reconsiderations, denials, and peer-to-peer reviews.