Maryland Licensed Utilization Management Nurse

Job Summary

Utilizing clinical expertise, the contract Maryland Licensed Utilization Management Nurse will perform remote utilization reviews to assess medical necessity and appropriateness of care while collaborating with internal teams and Medical Directors during standard working hours, with flexible start times.

Key responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for medical and behavioral health services
• Make determinations on medical necessity and support prior authorizations using clinical criteria and policy resources
• Collaborate with internal partners and providers to ensure services align with coverage and guidelines while maintaining 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 guidelines and supporting Commercial/FEP/Medicare lines of business
• Proficiency in web-based tools and Microsoft Office (Word/Excel/PowerPoint)