Utilization Review Nurse

Company Description
Lumen Solutions Group Inc. is a technology consulting Services company based in Florida. We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, Enterprise Transformation. 

Role: Utilization Review Nurse
Location: Baltimore MD(Remote)
Type: Contract

Job Description:
We are seeking an experienced Utilization Review Nurse (LPN or RN) to support high-volume clinical reviews for commercial and FEP health plans. The ideal candidate will have strong utilization management and care management experience, expertise with MCG guidelines, and the ability to manage a fast-paced review environment while ensuring quality and compliance.

Must-Have Requirements

• Active and unrestricted LPN (Compact State License) or RN license.
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of care management and/or utilization review experience
• Strong experience performing:
  • Inpatient reviews
  • Inpatient admissions reviews
  • Surgical procedure reviews
  • Infertility reviews
  • Home health reviews
• Hands-on experience using MCG (Milliman Care Guidelines) — mandatory.
• Strong understanding of evidence-based clinical guidelines and medical necessity criteria.
• Ability to work in a high-volume production environment handling approximately 30–35 reviews per day.
• Strong documentation, communication, and critical-thinking skills.

Key Responsibilities

• Perform utilization and medical necessity reviews for inpatient admissions, surgeries, home health, infertility, and related services.
• Apply MCG guidelines to determine appropriate level of care and authorization decisions.
• Review clinical documentation to ensure compliance with payer policies and regulatory requirements.
• Maintain productivity and quality standards in a high-volume review environment.
• Collaborate with care management teams, providers, and internal stakeholders.
• Accurately document review outcomes and authorization determinations in the system.