Utilization Review Specialist (RN, LPN)

Location: Maryland area; candidates must hold a Maryland-issued or Compact State RN or LPN license.

Company

hirify.global is supporting a major healthcare payor in the Maryland area.

What you will do

• Perform prospective, concurrent, and retrospective utilization reviews for authorization, appropriateness of care, and benefit coverage.
• Analyze clinical information, contracts, mandates, medical policies, evidence-based research, accreditation standards, and regulatory requirements.
• Determine medical necessity using MCG, Apollo, ASAM, Medicare, Federal Employee Program, and applicable policy guidelines.
• Research diseases, treatments, emerging technologies, and high-cost services to support recommendations to medical directors.
• Collaborate with medical directors, providers, contracting, member services, and sales and marketing teams on benefit application and case-rate negotiations.
• Refer members to appropriate care settings and present educational topics to internal audiences.

Requirements

• Maryland-issued or Compact State RN or LPN license required.
• Bachelor's degree in Nursing.
• Clinical nursing and utilization review experience, including up to 8 years of clinical nursing experience and 5 years as a Utilization Review Specialist.
• Experience in care management; critical care or emergency room experience is highly preferred.
• Knowledge of Milliman Care Guidelines (MCG) required.
• Experience with GuidingCare (HealthEdge) and knowledge of Facets required. Strong assessment, communication, confidentiality, web technology, and Microsoft Office skills are also required.

Nice to have

• Nasco experience.
• Critical care or emergency room background.

Culture & Benefits

• Work involves supporting members and healthcare providers across Commercial, Federal, and Medicare lines of business.
• Regular collaboration with clinical, provider, contracting, member services, and medical director stakeholders.
• Handling confidential member information and protected health information is part of the role.