Clinical Review Nurse Remote Jobs in Reston, VA (NOW HIRING)

Come join the iMPROve Health team!

About iMPROve Health

iMPROve Health is Michigan’s Medicare-designated Quality Improvement Organization, and we’re proud to be recognized as both a Cool Place to Work by Crain’s Detroit Business (four years running) and one of Modern Healthcare’s Best Places to Work in Healthcare.

As a nonprofit with more than 40 years of experience, we’re dedicated to improving healthcare across the continuum of care using evidence-based, data-driven strategies. We provide medical consulting and review services, along with data analysis, to federal agencies, state Medicaid programs, public health organizations, healthcare facilities, private health plans, and other third-party payers. Our team also specializes in impartial utilization review, dispute resolution, and peer review. Our mission is simple: help healthcare get better.

This position is 100% remote, offering the flexibility to work from anywhere in the United States while collaborating with a supportive, nationwide team.

At iMPROve Health, we are committed to improving the quality, safety, and efficiency of healthcare. While we do not provide direct patient care, our healthcare professionals—including physicians, nurses, and experienced consultants—partner with providers to promote the use of evidence-based best practices. We offer our clients a trusted, impartial resource that understands the complexities of the healthcare landscape and is dedicated to thoughtful, high-quality solutions.

Join us in making a meaningful impact on healthcare—one improvement at a time.

About the Role

iMPROve Health is seeking an experienced Michigan-licensed Registered Nurse (RN) to join our team as a Contingent Utilization Review / Long-Term Services & Supports (UR/LTSS) Review Nurse. This fully remote position supports Michigan Medicaid programs by conducting Nursing Facility Level of Care (LOC) reviews and Home Help quality review assessments.

This role is ideal for experienced nurses with both Utilization Review/Utilization Management (UR/UM) and Long-Term Services & Supports (LTSS)/Long-Term Care experience who are looking for flexible, contingent work while remaining engaged in meaningful clinical practice.

Review nurses evaluate medical records, conduct telephonic and virtual assessments, apply established clinical and regulatory criteria, and ensure timely, accurate review determinations. This position also includes participation in administrative hearings and appeals when necessary.

Contingent nurses are expected to maintain regular availability of at least 4–8 hours per week, with opportunities for additional hours based on program needs. Most work is performed during normal business hours; however, occasional evening, weekend, or holiday work may be required.

Essential Responsibilities

• Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards.
• Conduct telephonic Nursing Facility Level of Care (LOC) reviews for Michigan Medicaid beneficiaries using established LTSS criteria.
• Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases.
• Conduct virtual Home Help assessments using Microsoft Teams for beneficiaries selected by the Michigan Department of Health and Human Services (MDHHS).
• Review medical records, assessments, care plans, and supporting clinical documentation to determine eligibility and medical necessity.
• Apply evidence-based clinical criteria and state regulations to support review determinations.
• Utilize a case management approach from case assignment through completion while meeting established turnaround times.
• Document review findings accurately, thoroughly, and professionally within secure electronic systems and state portals.
• Communicate effectively with providers, beneficiaries, and internal staff regarding review findings and requests for additional information.
• Participate in administrative hearings and appeals to represent review determinations when required.
• Maintain current knowledge of contractual requirements, Medicaid regulations, and applicable clinical guidelines.
• Comply with all applicable HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements.
• Participate in required training, calibration, and quality assurance activities.
• Perform other duties as assigned.

Minimum Qualifications

• Active, unrestricted Michigan Registered Nurse (RN) license required.
• Long-Term Care/LTSS experience is required.
• Utilization Review (UR) and/or Utilization Management (UM) experience is required.
• Minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS.
• Bachelor’s degree in nursing preferred. Equivalent experience may be considered in lieu of a bachelor's degree.
• Experience working with Michigan Medicaid or other state-based healthcare contracts preferred.
• Strong knowledge of Medicare, Medicaid, Long-Term Services & Supports (LTSS), Nursing Facility Level of Care (LOC) determinations, and long-term care regulations preferred.
• Excellent clinical assessment, critical thinking, analytical, and documentation skills.
• Strong written, verbal, and interpersonal communication skills, including the ability to explain and defend clinical review determinations.
• Experience with electronic health records, secure web-based portals, and Microsoft Office applications, including Outlook, Teams, Word, and Excel.
• Ability to work independently in a remote environment while consistently meeting productivity, quality, and timeliness expectations.

Work Schedule

• Fully remote, contingent position.
• Minimum availability of 4–8 hours per week is required to maintain program engagement.
• Additional hours may be available based on workload and program needs.
• Most work is completed during normal business hours.
• Occasional evening, weekend, or holiday work may be required to meet operational deadlines.

Why Join iMPROve Health?

At iMPROve Health, our mission is to improve healthcare quality and outcomes through objective clinical review and quality improvement services. Our clinical professionals play a vital role in ensuring Medicaid beneficiaries receive appropriate, high-quality care while supporting the integrity of state healthcare programs.

If you are an experienced Michigan RN with both utilization review and long-term care expertise and are seeking flexible, meaningful work that makes a difference, we encourage you to apply.

EOE/VET/Disability