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LTSS Appeals Nurse (Remote)

We are seeking a detail-oriented, self-motivated Registered Nurse to join our team as an LTSS Appeals Nurse. In this role, you will perform high-volume clinical reviews within the appeals process, evaluating complex medical records and Long-Term Services and Supports (LTSS) benefits against regulatory and medical necessity criteria.

Job Responsibilities

• Conduct 10-13 clinical reviews per day within the established appeals process.

• Review and analyze clinical records, including comparative evaluations of members' two most recent assessments.

• Evaluate documentation against applicable benefit, medical necessity, and regulatory standards.

• Review LTSS benefits, service authorizations, and related determinations.

• Prepare concise, accurate clinical summaries and synthesized findings for the Medical Director.

• Research and interpret clinical data to support appropriate appeal decisions.

• Thoroughly document findings, determinations, and rationale within internal systems.

• Communicate service reductions, benefit changes, or denials to members and providers in a professional, clear, and empathetic manner.

• Collaborate with Medical Directors, clinical leadership, and cross-functional teams throughout the review process.

• Identify documentation discrepancies or missing clinical info, proactively obtaining necessary details.

• Support departmental quality and process-improvement initiatives.

• Maintain strict confidentiality while adhering to all organizational policies and healthcare regulations.

Required Qualifications

• Education & Licensure: ASN or BSN degree with an active, unrestricted New York Registered Nurse (NY RN) license.

• Residency: Must reside in New York (NY), New Jersey (NJ), or Connecticut (CT).

• Clinical Experience: Minimum 3 years of relevant nursing/healthcare experience, with dedicated experience involving Long-Term Services and Supports (LTSS).

• Review Expertise: Direct experience reviewing medical records, performing utilization review, appeals, grievances, or clinical management activities.

• Core Competencies: Strong understanding of healthcare benefits, service determinations, and medical necessity criteria.

• Communication: Exceptional written communication skills for synthesizing complex cases, paired with the ability to empathetically communicate difficult decisions (reductions/denials).

• Technical Skills: Strong computer proficiency and experience working with electronic medical record systems.

• Workstyle: Proven ability to independently manage high daily review volumes in a remote environment.

Preferred Qualifications

• Experience with Personal Care Aide (PCA) benefits and the Consumer Directed Personal Assistance Program (CDPAP).

• Prior experience in Medicaid managed care, health plans, or managed care organizations.

• In-depth knowledge of NYS healthcare regulations and managed-care requirements.

• Background in preparing clinical summaries directly for Medical Directors.

• Prior experience in quality management or clinical quality initiatives.

Schedule & Location Requirements

• Work Location: Remote (Must be located in NY, NJ, or CT).

• Shift: Flexible standard Monday-Friday business hours (e.g., 8:00 AM - 4:00 PM, 9:00 AM - 5:00 PM, or 10:00 AM - 6:00 PM).

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?