Maryland Licensed Utilization Management Nurse

Job Summary

Utilizing clinical expertise and a strong background in utilization management, the contract Maryland Licensed Utilization Management Nurse will perform remote reviews of care requests to assess medical necessity and appropriateness, working Monday to Friday from 8:00 am to 5:00 pm ET 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 teams and Medical Directors to ensure accurate authorization decisions and maintain documentation standards

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 applications