Utilization Review Specialist (Government, RN, LPN)

Location: Fully remote for candidates residing in DC, Maryland, Virginia, West Virginia, North Carolina, Pennsylvania, Delaware, New York, New Jersey, Texas, or Florida

Company

hirify.global provides staffing and technical services while supporting a major healthcare payer in the Maryland area.

What you will do

• Perform prospective, concurrent, and retrospective utilization reviews for medical and behavioral health services.
• Determine medical necessity, appropriateness of care, authorization, and benefit coverage using clinical guidelines, contracts, policies, and regulatory requirements.
• Research diseases, treatments, emerging technologies, and high-cost services to support recommendations to medical directors.
• Collaborate with medical directors, provider contracting, providers, facilities, sales and marketing, and member services.
• Coordinate non-par provider and facility case-rate negotiations and assist with benefit determinations.
• Refer members and providers to appropriate alternative care settings and present educational topics to internal audiences.

Requirements

• Bachelor's degree in Nursing.
• Maryland-issued or Nurse Licensure Compact license as an RN or LPN is required.
• Five years of clinical nursing experience and at least two years of utilization review or utilization management experience.
• Two years of care management experience; critical care or emergency room experience is highly preferred.
• Required knowledge of Milliman Care Guidelines and experience with the GuidingCare/HealthEdge platform.
• Strong knowledge of clinical guidelines, medical policies, accreditation and regulatory standards, assessment, communication, confidential member data, PHI, and Microsoft Office.

Nice to have

• Medicare, Medicaid, or DNSIPS experience.
• Experience with Facets or Nasco.
• Working knowledge of managed care and healthcare delivery systems.

Culture & Benefits

• Fully remote work arrangement within the listed U.S. states.
• Work involves collaboration with clinical, provider, contracting, sales, marketing, and member services teams.
• Regular interaction with members and healthcare professionals by telephone and other web-based tools.