Maryland Licensed Utilization Management Nurse

Job Summary

Utilizing clinical expertise, the contract Maryland Licensed Utilization Management Nurse will perform remote utilization reviews, making determinations on medical necessity and appropriateness while collaborating with internal teams and Medical Directors during standard working hours of 8:00am-5:00pm ET.

Key responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for medical and behavioral health services
• Make determinations regarding medical necessity and support prior authorizations using clinical criteria and policy resources
• Collaborate with internal partners and providers to ensure services align with coverage guidelines and maintain accurate documentation

Required qualifications

• Active RN or LPN license (RN preferred) with Maryland compact/eligibility required
• 5+ years of clinical nursing experience
• 2+ years of care management or utilization management experience
• Experience with MCG and supporting Commercial/FEP/Medicare lines of business
• Proficient with web-based tools and Microsoft Office (Word/Excel/PowerPoint)