Utilization Review Specialist (Government, RN, LPN)

Introduction:

Elite Technical is seeking a Maryland or Nurse Licensure Compact (NLC) certified (RN or LPN) Utilization Review Specialist to support our customer, a major Healthcare payor in the Maryland area. We are seeking candidates who have 5 years of experience as a Nurse, 2 years in a Utilization Management role, and have an understanding of Milliman Care Guidelines (MCG) and Guidingcare/Healthedge.

Responsibilities:

The Utilization Review Specialist will be responsible for performing prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Key responsibilities include:

• Determining medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, and medical guidelines.
• Conducting research and analysis of diseases, treatments, and emerging technologies to support decisions and recommendations.
• Making appropriate referrals and contacts as needed and offering assistance to members and providers for alternative care settings.

Requirements:

Required Skills:

• Active Maryland or Nurse Licensure Compact (NLC) certification as an RN or LPN.
• 5 years of experience as a Nurse.
• 2 years of experience in a Utilization Management role.
• Understanding of Milliman Care Guidelines (MCG) and Guidingcare/Healthedge.

Preferred Skills:

• Experience with Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, and other medical references.
• Familiarity with NCQA Standards, medical policies, and departmental SOPs.
• Knowledge of Commercial, Federal, and Medicare policies.