Utilization Management RN – LTSS (Hybrid - APX 75% Remote)

Job Description:

Candidates must live in Massachusetts and hold an active, unrestricted Massachusetts RN license at the time of hire.

This is a hybrid position, approximately 75% remote and 25% in person for meetings, training and backup support as business needs require. Occasional direct member interaction may be required. Work arrangements may change based on business needs.

The LTSS Nurse Liaison owns clinical determination and authorization support for members receiving Long Term Services and Supports. This role synthesizes assessment data, visit documentation, and external care and agency records to establish a member’s current functional level, produces the clinical determination and supporting rationale for initial requests and annual redeterminations, and manages the ongoing clinical exchange with health plan Utilization Management teams.

The Liaison also manages a dedicated appeal queue, confirming that appeal justifications have been reviewed directly with the member and that submitted packets are complete and defensible. The role operates at the intersection of clinical judgment, regulatory compliance, and financial stewardship, and partners closely with market care teams, external service agencies, and health plan clinical staff.

The Liaison does not issue coverage denials, does not communicate coverage decisions to members as final, and escalates any case in which clinical criteria and financial interest appear to diverge to clinical leadership and Compliance. Determinations are subject to internal quality review and inter-rater reliability monitoring.

• Clinical Credential: Active, unrestricted Registered Nurse (RN) or Nurse Practitioner (NP) license in good standing in Massachusetts. Additional state licensure or multistate compact privileges preferred.
• Education: Graduate of an accredited school of nursing.
• Experience: 3 or more years of clinical experience, with direct experience in utilization management, clinical review, or medical necessity determination strongly preferred.
• LTSS Exposure: Working familiarity with long term services and supports, including home and community based services, personal care services, adult day health, home health, and durable medical equipment. Experience with functional assessment instruments (MDS-HC, MDS, or state equivalent) preferred.
• Regulatory Familiarity: Understanding of MassHealth LTSS coverage criteria and of Medicaid and Medicare Advantage authorization, appeal, and grievance processes, including Board of Hearings procedure and continuation of services during appeal.
• Population Experience: Experience serving dually eligible, medically complex, or behavioral health involved populations.

Skills and Competencies

• Clinical Judgment: Synthesizes incomplete and conflicting documentation into a defensible functional picture, and recognizes when the record is insufficient to support a determination and what is needed to close the gap.
• Written Precision: Produces clear, criteria anchored clinical narrative that survives external review without supplementation.
• Queue Discipline: Manages competing deadlines independently without daily direction, and maintains accurate status visibility on every open case.
• External Communication: Holds professional, productive clinical conversations with plan Utilization Management nurses and medical directors, including in disagreement.
• Member Centered Practice: Versed in Motivational Interviewing and Trauma Informed Care principles; engages members on service adjustments and appeal decisions with candor and respect.
• Systems Proficiency: Proficient in electronic health record and care facilitation platforms (Commons, Athena) and telephony tooling (TalkDesk), and documents accurately and contemporaneously across systems that do not integrate cleanly.
• Problem Solving: Resolves day to day review and coordination issues guided by policy and established process, and knows when to escalate rather than interpret.
• Flexibility: Adaptable to frequent change in plan requirements, regulation, criteria sets, and internal workflow.
• Language: Proficiency in multiple languages is a plus and is not required for the role.

Registered Nurses and Community Health Partners on market care teams, RN Lead, Senior Director of Care Management, Assessment RN and Assessment RN Manager, Advanced Practice Clinicians and Medical Doctors, Behavioral Health team, Pharmacy, Care Team Operations, Quality, Compliance, health plan Utilization Management staff, and external LTSS service agencies.

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: 

Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.