Utilization Review Specialist (RN, LPN)

Introduction:

We are looking for a Maryland or Compact State certified Utilization Review Specialist (RN or LPN) to join our team and support a major Healthcare payor in the Maryland area. The ideal candidate will have extensive experience in nursing, utilization management, and a deep understanding of Milliman Care Guidelines (MCG).

Responsibilities:

• Determine medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, and other accepted medical/pharmaceutical references.
• Conduct research and analysis of diseases, treatments, and emerging technologies to support decisions and recommendations to medical directors.
• Make appropriate referrals and contacts as necessary and provide assistance to members and providers for alternative care settings.
• Collaborate with various stakeholders to determine appropriate benefit application and coordinate provider/facility negotiations.
• Research and present educational topics related to cases, disease entities, and treatment modalities to internal audiences.

Requirements:

Required Skills:

• Bachelor''s Degree in Nursing
• Maryland Issued or Compact State License LPN or RN Nurse
• 5 years of Clinical nursing experience
• 2 years of Care Management (Critical care and/or ER experience highly preferred)
• Knowledge of Milliman Care Guidelines (MCG)
• 8 years of Clinical nursing experience with 5 years as a Utilization Review Specialist
• Experience with Guidecare (Healthedge) platform
• Knowledge of Facets
• Working knowledge of managed care and health delivery systems
• Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards
• Effective written and interpersonal communication skills
• Strong assessment skills with the ability to connect with members telephonically
• Ability to work with confidential member data and PHI
• Proficiency in web-based technology and Microsoft Office applications