REMOTE SNF Utilization Management RN - 258990

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

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...