Utilization Review Specialist

Please, no agencies or recruiters, only W2 applicants.

Vega Consulting is staffing a Utilization Review Specialist for our direct Healthcare client. This is a 6-month contract, hybrid role. Candidates license for Maryland, VA or Wash DC. (RN or LPN).

The Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and/or adjudication. The incumbent will handle pre and post claim medical review for Commercial, and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions.

Candidates job Requirement:

• 3 years acute clinical experience, previous case management, discharge planning or utilization review experience
• Maryland BCBA license OR Virginia BCBA license OR Washington DC BCBA license
• RN/LPN state licensing or compact
• Ambulatory Practice
• Candidate must be willing to travel to provider locations to retrieve medical records
• Remote EMR Access
• Education Level: Bachelor's Degree
• Remote EMR access is essential as well as ambulatory practice experience
• 5 years Clinical nursing experience
• 2 years Care Management
• Education Details: Nursing
• Ability to effectively communicate and provide positive customer service to every internal and external customer, Proficient
• Strong interpersonal skills. Ability to work independently, as well as a member of a team , Advanced
• Current knowledge of clinical practices and related medical policies., Proficient
• Strong organizational skills, ability to prioritize responsibilities with attention to detail., Proficient
• Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology., Proficient
• Must possess excellent verbal and written communication skills. , Advanced

If you are a RN or LPN seeking a hybrid based position, select "Apply Now" and a Vega Staffing Specialist will reach out to you.