Maryland Licensed Utilization Management Specialist

Job Summary

Working remotely on a contract basis, the Maryland Licensed Utilization Management Specialist will review requests for care, determine medical necessity, and support prior authorizations while collaborating with Medical Directors and internal teams.

Key responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews for medical and behavioral health
• Make medical necessity determinations and ensure compliance with clinical criteria and policy resources
• Collaborate with internal partners and providers to manage caseloads and maintain accurate documentation

Required qualifications

• Active RN or LPN license in Maryland (RN preferred)
• 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 (Word/Excel/PowerPoint)