Maryland Licensed Utilization Management Specialist

Job Summary

Utilizing clinical expertise, the contract Maryland Licensed Utilization Management Specialist will perform remote utilization reviews and make determinations on medical necessity and appropriateness while collaborating with internal teams and Medical Directors.

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 in Maryland (RN preferred) with 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 Microsoft Office and web-based tools