Maryland Licensed Utilization Management Specialist

Job Summary

Utilizing clinical expertise and experience in utilization management, the contract Maryland Licensed Utilization Management Specialist will perform remote reviews of care requests to determine medical necessity and appropriateness, 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 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 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 and supporting Commercial/FEP/Medicare lines of business
• Proficiency with web-based tools and Microsoft Office applications