Long Term Services and Support Nurse RN - Part Time (remote)
About iMPROve Health
Come join the iMPROve Health team! iMPROve Health is Michigan’s Medicare-designated Quality Improvement Organization. We are both a Cool Place to Work (Crain’s Detroit Business) for the last 4 years and one of the Best Places to Work in Healthcare as judged by Modern Healthcare. As a nonprofit organization, we have more than 35 years’ experience improving healthcare across the continuum of care using evidence-based and data-driven logic. iMPROve Health provides medical consulting and review, as well as data analysis to federal agencies, state Medicaid and public health organizations, healthcare facilities, private health plans and other third-party payers. We also have extensive experience completing thoughtful and impartial utilization review, dispute resolution and peer reviews. Our goal is simple – to help healthcare get better!
This position is 100% remote and provides the opportunity to work virtually with team members from anywhere within the United States. We pride ourselves on providing a great work/life balance for employees, while also providing the ability to promote their career development and gain new skills through employee education opportunities. iMPROve Health offers a wonderful benefit package that includes medical, dental, vision, life insurance, short term and long-term disability, and a generous 401k match.
iMPROve Health is committed to improving the quality, safety, and efficiency of healthcare. Although we do not see patients, we are healthcare professionals (including physicians and nurses) and consultants who work with healthcare providers to promote the adoption and use of evidence-based best practices and processes to achieve our healthcare quality goals. Our services offer our clients and partners access to a proven, impartial, connected resource that understands the intricacies of healthcare. It is our #1 priority to provide thoughtful evidence-based strategies and solutions that help them achieve their healthcare quality improvement goals and outcomes.
iMPROve Health is an equal employment opportunity employer
****This is position is part-time. Candidates need to have flexibility to work 20-24 hours per week. There is flexibility in the days of the week work will be performed.***
SUMMARY:
Long-term service and support (LTSS) review nurses are responsible for the nursing facility level of care (LOC) Review Process and assessments performed for the Home Help program. This process includes verification, secondary, and quality reviews.
For nursing facility level of care reviews, the RN reviews cases that are either selected by MDHHS or are requested by the provider or Medicaid beneficiary to see if the Medicaid recipient is meeting the eligibility requirements for nursing facility level of care. This review involves beneficiaries entering nursing facilities, MI Choice Waiver, MI Health Link, or PACE programs. It also involves beneficiaries who may have been eligible at one time, but their condition has changed. For the Home Help program, the RN reviews cases and performs electronic assessments that are selected by MDHHS as requiring a quality review audit for certain beneficiaries needing help in their homes.
Most reviews are completed on the State’s secure system. RNs may be required to represent their review decision at an appeal. These appeals are usually performed telephonically, although, some travel may be necessary.
DUTIES AND RESPONSIBILITIES:
- Performs telephonic review for Long-term care review.
Expectation: appropriately apply LTSS exception criteria and LTSS Level of Care Determinations to all cases.
- Performs telephonic or Microsoft Teams assessments for beneficiaries of the Home Help program.
Expectation: appropriately apply nursing skills assessment and chart audit to all selected beneficiaries.
- Utilizes the case management approach to handle telephonic, state-selected verification reviews, and quality reviews.
Expectation: follow the case from request until completion and generate the appropriate letter to be sent on any case.
- Maintains current knowledge of contractual and regulatory requirements.
Expectation: stay current with all MDHHS bulletins, manual changes or contract updates.
- Assures that reviews are completed timely
Expectation: answer calls on an average of 90 seconds or less per the requirement of MDDHS and complete all reviews within contract timeline as applicable.
- Participate in hearings and appeals
Expectation: represent their review decisions at appeals and prepare the appeal packet and distribute to required parties.
- Adhere to all relevant compliance regulations (HIPAA, FISMA, URAC, CMS).
Expectations: maintain up to date knowledge, training and adherence with all compliance and regulatory requirements for contracts, governmental and compliance regulatory organizations.
DUCATION AND/OR EXPERIENCE:
- Bachelor’s Degree in Nursing preferred. Equivalent years of experience will be considered
- Long term care experience required
- Current Michigan license as a Registered Nurse required
- Experience working with State based contracts preferred
- Five years of utilization and/or health care experience required
- Strong verbal and written communication skills required, including public speaking
COMPUTER SKILLS:
- Proficient in Microsoft Outlook, Word, Excel, and Teams
- Working knowledge of PowerPoint, Microsoft Access and Visio
- Proficient in online portals requiring authentication.
- Proficient in responsibilities of remote work
About iMPROve Health
Come join the iMPROve Health team! iMPROve Health is Michigan’s Medicare-designated Quality Improvement Organization. We are both a Cool Place to Work (Crain’s Detroit Business) for the last 4 years and one of the Best Places to Work in Healthcare as judged by Modern Healthcare. As a nonprofit organization, we have more than 35 years’ experience improving healthcare across the continuum of care using evidence-based and data-driven logic. iMPROve Health provides medical consulting and review, as well as data analysis to federal agencies, state Medicaid and public health organizations, healthcare facilities, private health plans and other third-party payers. We also have extensive experience completing thoughtful and impartial utilization review, dispute resolution and peer reviews. Our goal is simple – to help healthcare get better!
This position is 100% remote and provides the opportunity to work virtually with team members from anywhere within the United States. We pride ourselves on providing a great work/life balance for employees, while also providing the ability to promote their career development and gain new skills through employee education opportunities. iMPROve Health offers a wonderful benefit package that includes medical, dental, vision, life insurance, short term and long-term disability, and a generous 401k match.
iMPROve Health is committed to improving the quality, safety, and efficiency of healthcare. Although we do not see patients, we are healthcare professionals (including physicians and nurses) and consultants who work with healthcare providers to promote the adoption and use of evidence-based best practices and processes to achieve our healthcare quality goals. Our services offer our clients and partners access to a proven, impartial, connected resource that understands the intricacies of healthcare. It is our #1 priority to provide thoughtful evidence-based strategies and solutions that help them achieve their healthcare quality improvement goals and outcomes.
iMPROve Health is an equal employment opportunity employer
****This is position is part-time. Candidates need to have flexibility to work 20-24 hours per week. There is flexibility in the days of the week work will be performed.***
SUMMARY:
Long-term service and support (LTSS) review nurses are responsible for the nursing facility level of care (LOC) Review Process and assessments performed for the Home Help program. This process includes verification, secondary, and quality reviews.
For nursing facility level of care reviews, the RN reviews cases that are either selected by MDHHS or are requested by the provider or Medicaid beneficiary to see if the Medicaid recipient is meeting the eligibility requirements for nursing facility level of care. This review involves beneficiaries entering nursing facilities, MI Choice Waiver, MI Health Link, or PACE programs. It also involves beneficiaries who may have been eligible at one time, but their condition has changed. For the Home Help program, the RN reviews cases and performs electronic assessments that are selected by MDHHS as requiring a quality review audit for certain beneficiaries needing help in their homes.
Most reviews are completed on the State’s secure system. RNs may be required to represent their review decision at an appeal. These appeals are usually performed telephonically, although, some travel may be necessary.
DUTIES AND RESPONSIBILITIES:
- Performs telephonic review for Long-term care review.
Expectation: appropriately apply LTSS exception criteria and LTSS Level of Care Determinations to all cases.
- Performs telephonic or Microsoft Teams assessments for beneficiaries of the Home Help program.
Expectation: appropriately apply nursing skills assessment and chart audit to all selected beneficiaries.
- Utilizes the case management approach to handle telephonic, state-selected verification reviews, and quality reviews.
Expectation: follow the case from request until completion and generate the appropriate letter to be sent on any case.
- Maintains current knowledge of contractual and regulatory requirements.
Expectation: stay current with all MDHHS bulletins, manual changes or contract updates.
- Assures that reviews are completed timely
Expectation: answer calls on an average of 90 seconds or less per the requirement of MDDHS and complete all reviews within contract timeline as applicable.
- Participate in hearings and appeals
Expectation: represent their review decisions at appeals and prepare the appeal packet and distribute to required parties.
- Adhere to all relevant compliance regulations (HIPAA, FISMA, URAC, CMS).
Expectations: maintain up to date knowledge, training and adherence with all compliance and regulatory requirements for contracts, governmental and compliance regulatory organizations.
DUCATION AND/OR EXPERIENCE:
- Bachelor’s Degree in Nursing preferred. Equivalent years of experience will be considered
- Long term care experience required
- Current Michigan license as a Registered Nurse required
- Experience working with State based contracts preferred
- Five years of utilization and/or health care experience required
- Strong verbal and written communication skills required, including public speaking
COMPUTER SKILLS:
- Proficient in Microsoft Outlook, Word, Excel, and Teams
- Working knowledge of PowerPoint, Microsoft Access and Visio
- Proficient in online portals requiring authentication.
- Proficient in responsibilities of remote work
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