Utilization Review (MDS) – RN/LPN

Location: Valley Stream, New York
Job Type: Full-Time
Schedule: Hybrid (Onsite Required 4 Days per Week)
Compensation: $90,000 – $125,000 annually (DOE)

About the Role

We are seeking an experienced Utilization Review (MDS) RN/LPN to support Skilled Nursing Facility (SNF) operations and ensure accurate clinical review, care coordination, and reimbursement optimization. This position plays a key role in managing utilization review activities, supporting MDS-related processes, and collaborating with interdisciplinary teams to achieve positive clinical and financial outcomes.

The ideal candidate will possess a strong background in skilled nursing, utilization review, managed care, and reimbursement processes.

Key Responsibilities

Utilization Review & MDS Management

• Conduct utilization review activities for SNF residents to ensure appropriate level of care and reimbursement.

• Review admissions, continued stays, payer changes, and discharge planning activities.

• Coordinate prior authorizations, clinical updates, denials, reconsiderations, and appeals with managed care organizations.

• Monitor reimbursement opportunities and ensure compliance with payer guidelines and regulatory requirements.

• Collaborate with interdisciplinary teams to support care planning and clinical outcomes.

• Review and analyze MDS assessments for accuracy, completeness, and reimbursement optimization.

• Participate in utilization review meetings and daily census management activities.

• Ensure timely issuance and submission of denial notices, NOMNCs, and related documentation.

• Maintain detailed and accurate records of all utilization management activities.

Qualifications

Required

• Active and unrestricted RN or LPN license.

• Minimum 3 years of experience in Skilled Nursing Facilities (SNF), utilization review, MDS coordination, managed care, case management, or related healthcare settings.

• Strong understanding of:

  • MDS processes and reimbursement methodologies

  • Utilization review and utilization management

  • Prior authorizations and payer requirements

  • Denials management and appeals

  • Medicare, Medicaid, and managed care reimbursement

• Experience working with EMR systems and insurance portals.

• Excellent organizational, communication, and problem-solving skills.

• Ability to manage multiple priorities in a fast-paced environment.

Preferred

• RAC-CT, CPC, CPUR, CCM, or related certifications.

• Experience working within the New York healthcare market.

Why Join Us?

• Competitive salary: $90,000 – $125,000 DOE

• Hybrid work schedule with strong work-life balance

• Opportunity to make a direct impact on patient outcomes and reimbursement success

• Collaborative interdisciplinary team environment

• Professional growth and advancement opportunities

• Stable and growing healthcare organization

How to Apply

If you are an experienced RN or LPN professional with expertise in Utilization Review, MDS, and managed care, we encourage you to apply and become part of a team dedicated to delivering exceptional patient care while ensuring operational excellence.

Apply today to advance your healthcare career with a meaningful and impactful role.

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