Job Title: Utilization Management - RN/LPN (Care Management)
Location: Baltimore, MD
Duration: 12 Months+
Purpose:
Supports the Utilization Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to pre-service, utilization review, care coordination and quality of care.
Essential Functions:
35% Performs member or provider related administrative support which may include benefit verification, authorization creation and management, claims inquiries and case documentation.
35% Reviews authorization requests for initial determination and/or triages for clinical review and resolution.
20% Provides general support and coordination services for the department including but not limited to answering and responding to telephone calls, taking messages, letters and correspondence, researching information and assisting in solving problems.
10% Assists with reporting, data tracking, gathering, organization and dissemination of information such as Continuity of Care process and tracking of Peer to Peer reviews.
Required Experience:
3 years’ experience in health care claims/service areas or office support.
5+ years of Utilization Management / Clinical Patient Care experience
3+ years of Care Management experience
Strong hands-on experience with MCG (Milliman Care Guidelines)
Active RN or LPN compact license (required)
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