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

cityblockhealth; United States; Hybride; USD 95 000 - 125 000; Plein temps

Résumé du poste

Cityblock Health is seeking a Lead LTSS Nurse Liaison in Massachusetts. The role entails synthesizing assessments, producing clinical determinations, and coordinating with Utilization Management to support long-term services and supports.

The position blends remote and in-person work and requires strong documentation and regulatory compliance. The role also manages an appeals queue, ensures decisions are well-supported, and collaborates with market care teams and external agencies to safeguard

Qualifications

• Active, unrestricted Massachusetts RN license at time of hire.
• Experience with LTSS and plan review is a plus.

Responsabilités

• Perform clinical reviews and functional assessments against level-of-care criteria.
• Develop clinical determinations and rationales for initial requests and redeterminations.
• Submit determinations to Utilization Management and coordinate clinical exchanges.
• Manage an appeals queue and prepare materials for hearings.
• Maintain daily queue management and prioritize by deadlines.
• Collaborate with market care teams, external LTSS service agencies, and health plan staff.
• Ensure audit-ready documentation and ICD/CPT coding compliance.
• Adapt to regulatory changes and translate them into practice.

Connaissances

Clinical judgment

Regulatory compliance

Documentation

Formation

Massachusetts RN license

Description du poste

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 Responsibilitie s

• 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 com