Maryland Licensed Utilization Management Specialist

Job Summary

Utilizing clinical expertise, the contract Maryland Licensed Utilization Management Specialist will conduct utilization reviews for medical necessity and appropriateness, working remotely with a flexible schedule while collaborating with internal teams and Medical Directors.

Key responsibilities

• Perform 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)