Registered Nurse – LTSS Case Management Liaison
$100k - $105k+ Equity program
Mid
Bachelor's
Massachusetts, USA
HybridMust live in Massachusetts; approximately 25% in-person for meetings, training, and backup support, with arrangements subject to change.
Medical, Clinical & Veterinary
About the job
Requirements
- Hold an active, unrestricted Registered Nurse or Nurse Practitioner license in good standing in Massachusetts.
- Graduate from an accredited school of nursing.
- Have at least 3 years of clinical experience.
- Have 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.
- Understand MassHealth LTSS coverage criteria and Medicaid and Medicare Advantage authorization, appeal, and grievance processes, including Board of Hearings procedure and continuation of services during appeal.
- Have experience serving dually eligible, medically complex, or behavioral health-involved populations.
- Synthesize incomplete and conflicting documentation into a defensible functional picture, identify when the record is insufficient, and determine what information is needed to close the gap.
- Produce clear, criteria-anchored clinical narratives that can withstand external review without supplementation.
- Manage competing deadlines independently and maintain accurate status visibility on every open case.
- Conduct professional clinical conversations with health plan Utilization Management nurses and medical directors, including when there is disagreement.
- Apply Motivational Interviewing and Trauma-Informed Care principles when engaging members on service adjustments and appeal decisions.
- Be proficient in electronic health record and care facilitation platforms, including Commons and Athena, and telephony tooling such as TalkDesk; document accurately and contemporaneously across systems that do not integrate cleanly.
- Resolve day-to-day review and coordination issues using policy and established processes, and escalate issues when appropriate.
- Adapt to changes in plan requirements, regulation, criteria sets, and internal workflows.
Responsibilities
- Synthesize 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 members’ clinical and functional status against established level-of-care criteria.
- Identify documentation gaps that could weaken a determination and work with the assigned care team to close them before submission.
- Apply criteria specified by the applicable contract and state LTSS regulation to produce clinical determinations and written rationales for initial requests and annual redeterminations, including recommendations to continue, adjust, or discontinue services.
- Submit clinical determinations and supporting documentation to health plan Utilization Management teams and manage ongoing clinical exchange through resolution, including responses to requests for additional information and clinician-to-clinician discussions where required.
- Serve as the standing clinical point of contact for plan partners on LTSS review matters.
- Manage a dedicated appeal queue end to end; confirm appeal justifications have been reviewed directly with members and that their stated goals and preferences are reflected in the packets.
- Assemble structured appeal submissions, track filing deadlines and continuation-of-services timelines, and prepare clinical summary materials for Board of Hearings proceedings.
- Escalate cases carrying adverse-precedent risk to clinical leadership and Compliance.
- Independently manage a daily queue of initial reviews, annual redeterminations, and ad hoc appeal requests against turnaround standards set by plan contracts and applicable regulations.
- Prioritize queue work by deadline exposure and member access risk, and flag volume or capacity constraints before turnaround standards are missed.
- Serve as the clinical bridge between market care teams, external LTSS service agencies, and health plan clinical staff.
- Use the RN Triage Needed workflow to route members requiring clinical escalation to the market team, and communicate changes in authorized service levels to the assigned care team for incorporation into the care plan and follow-up.
- Translate clinical determinations and their operational implications for non-clinical staff, members, and families.
- Document 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.
- Maintain consistency of criteria application across reviewers, participate in inter-rater reliability review, and raise recurring adverse decision patterns, criteria interpretation conflicts, and workflow friction with clinical and operational leadership.
- Adapt to changes in plan requirements, state regulation, criteria sets, and internal tooling, and help translate those changes into workable practices for market teams.
- Solicit and relay frontline feedback when LTSS review processes create friction for staff or members.
- Escalate cases in which clinical criteria and financial interests appear to diverge to clinical leadership and Compliance.
Desired Qualifications
- Direct experience in utilization management, clinical review, or medical necessity determination.
- Additional state licensure or multistate compact privileges.
- Experience with functional assessment instruments such as MDS-HC, MDS, or a state equivalent.
- Proficiency in multiple languages.
About the company
Cityblock Health provides integrated medical, mental health, and social services for underserved communities, with a focus on Medicaid and lower-income Medicare plans. It coordinates care through a dedicated team of doctors, nurses, social workers, and mental health advocates who tailor support to each member’s needs. Services include in-person clinics, virtual care, and mobile urgent care for non-life-threatening emergencies. Unlike traditional providers, Cityblock combines healthcare with social support (housing, food security, childcare, addiction help) to address root health factors. Financial assistance helps cover copays, often making care free at the point of use. The company’s goal is to improve health outcomes for marginalized populations by offering accessible, compassionate, and proactive care that reduces unnecessary ER visits and connects patients with comprehensive resources.
Company Size
501-1,000
Company Stage
Series E
Total Funding
$1.1B
Headquarters
New York City, New York
Founded
2017
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Simplify's Take
What believers are saying
- General Catalyst led Cityblock’s $116 million Series E on August 20, 2026.
- Cityblock reported $2.2 billion annualized revenue and nearly 200,000 members in August 2026.
- Homeward adds 50 counties and roughly 50,000 rural patients, widening payer reach.
What critics are saying
- Medicaid cuts and tighter Medicare Advantage rates squeeze margins immediately after August 2026.
- Homeward integration threatens execution across technology, data, and operations before 2027 renewals.
- If reimbursement compression outpaces growth, Cityblock’s capital-heavy model collapses under a 2027 cash crunch.
What makes Cityblock Health unique
- Cityblock’s August 2026 platform spans urban Medicaid and rural Medicare Advantage through Homeward.
- Its CORE operating system turns social, behavioral, and clinical data into care actions.
- Humana’s July 1, 2026 North Carolina contract validates 24/7 wraparound service delivery.
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Benefits
- Comprehensive health, dental, & vision coverage
- 12 weeks parental leave
- 401(k)
- 20 days vacation
- Company retreats & events