Utilization Management Nurse Specialist

Lumen Solutions Group Inc • Baltimore, MD

5h • Remote

About The Position

We are seeking an experienced Utilization Management Nurse Specialist to support utilization review and care management activities within a managed care environment. The ideal candidate will have a strong clinical nursing background, experience with utilization management processes, and proficiency with industry-standard care management tools and guidelines.

Requirements

• Active RN (preferred) or LPN license with a Maryland or Compact Nursing License.
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of Care Management experience.
• Previous Utilization Management or Utilization Review experience in a managed care or health insurance environment.
• Hands-on experience with: MCG (Milliman Care Guidelines)
• Hands-on experience with: GuidingCare
• Hands-on experience with: Facets
• Proficient with Microsoft Office and working across multiple systems.

Nice To Haves

• Critical Care or Emergency Room (ER) nursing experience.
• Experience supporting Blue Cross Blue Shield or other health insurance plans.
• Previous experience as a Utilization Management Specialist.

Responsibilities

• Review medical records and evaluate the medical necessity of healthcare services.
• Apply MCG (Milliman Care Guidelines) to make utilization management decisions.
• Perform utilization review and care management activities in accordance with payer policies.
• Collaborate with physicians, hospitals, and healthcare providers to coordinate patient care.
• Document reviews and maintain accurate case information using GuidingCare and Facets.
• Manage multiple applications while ensuring timely and accurate case processing.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed