Utilization Review Nurse, LTSS and HCBS - Remote in Michigan

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

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.

Primary Responsibilities:

• 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

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active and unrestricted RN license in the state of Michigan
• 3+ years of clinical experience
• 1+ years of experience in LTSS, HCBS, or managed care
• Solid knowledge of Medicaid programs, HCBS waiver services, and person-centered planning
• Proficiency in clinical documentation systems and utilization management platforms (e.g., ICUE, Community Care, OCM)
• Proven excellent communication, critical thinking, and organizational skills
• Must reside in Michigan

Preferred Qualifications:

• Certified Case Manager (CCM)
• Utilization Management certification
• Experience with D-SNP or similar Medicaid managed care programs
• Familiarity with risk stratification tools and interdisciplinary care planning
• Demonstrated ability to work independently and manage multiple priorities in a fast-paced environment

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.