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.

Key Responsibilities

Clinical Review and Functional Assessment: Synthesizes internal assessments (including MDS-HC and comprehensive member assessments where applicable), recent visit notes, medication reconciliation records, and external care and agency documentation to evaluate a member’s clinical and functional status against established level of care criteria. Identifies documentation gaps that would weaken a determination and works with the assigned care team to close them before submission rather than after an adverse decision.

Clinical Determination and Rationale Development: Applies the criteria set specified by the applicable contract and state LTSS regulation to produce the clinical determination and written rationale for initial requests and annual redeterminations, including the basis for recommending continuation, adjustment, or discontinuation of services. Written rationale is the primary work product of this role and is expected to withstand external clinical and legal review without supplementation.

Plan Coordination: Submits clinical determinations and supporting documentation to health plan Utilization Management teams and manages the ongoing clinical exchange through resolution, including responses to requests for additional information and clinician to clinician discussion where required. Serves as the standing clinical point of contact for plan partners on LTSS review matters.

Appeals and Hearing Preparation: Manages a dedicated appeal queue end to end. Confirms that the appeal justification has been reviewed directly with the member and that the member’s stated goals and preferences are reflected in the packet. Assembles structured appeal submissions, tracks filing deadlines and continuation of services timelines, and prepares clinical summary materials for Board of Hearings proceedings. Escalates cases carrying adverse precedent risk to clinical leadership and Compliance.

Queue and Turnaround Management: Independently manages a daily queue of initial reviews, annual redeterminations, and ad hoc appeal requests against turnaround standards set by plan contract and applicable regulation. Prioritizes by deadline exposure and member access risk, and flags volume or capacity constraints before turnaround standards are missed rather than after.

Cross Functional Collaboration: Serves as the clinical bridge between market care teams, external LTSS service agencies, and health plan clinical staff. Uses the RN Triage Needed workflow to route members requiring clinical escalation to the market team, and communicates changes in authorized service levels to the assigned care team so they are reflected in the care plan and addressed on the next call. Translates clinical determinations and their operational implications clearly for non-clinical staff, members, and families.

Internal Consistency and Audit Readiness: Documents all reviews, plan communications, and appeal activity in Commons and Athena in accordance with Cityblock standards and audit requirements, including accurate ICD and CPT documentation supporting clinical findings. Maintains consistency of criteria application across reviewers, participates in inter-rater reliability review, and surfaces recurring adverse decision patterns, criteria interpretation conflicts, and workflow friction to clinical and operational leadership.

Change Management: Adapts to changes in plan requirements, state regulation, criteria sets, and internal tooling, and helps translate those changes into workable practice for market teams. Solicits and relays frontline feedback where LTSS review processes create friction for staff or members.

Scope and Authority

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.

Education and Experience

• 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.

Working Collaborators

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:

100,000 - 105,000

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.

We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.