Utilization Management Nurse Specialist

Baltimore, MD
Remote

Instant Apply

30+ days ago

Job Description

Company Description
Lumen Solutions Group Inc. is a technology consulting Services company based in Florida. We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, and Enterprise Transformation.

Role: Utilization Management Nurse Specialist
Location: 100% Remote
Duration: 3-Month Contract (Potential for Extension)

Job Description:
We are seeking an experienced Utilization Management Nurse Specialist to support utilization review and care management activities within a managed care environment. The ideal candidate will have a strong clinicalnursing background, experience with utilization management processes, and proficiency with industry-standard care management tools and guidelines.

Position Overview

Review medical records and evaluate the medical necessity of healthcare services.
Apply MCG (Milliman Care Guidelines) to make utilization management decisions.
Perform utilization review and care management activities in accordance with payer policies.
Collaborate with physicians, hospitals, and healthcare providers to coordinate patient care.
Document reviews and maintain accurate case information using GuidingCare and Facets.
Manage multiple applications while ensuring timely and accurate case processing.

Required Qualifications

Active RN (preferred) or LPN license with a Maryland or Compact Nursing License.
Minimum 5 years of clinical nursing experience.
Minimum 2 years of Care Management experience.
Previous Utilization Management or Utilization Review experience in a managed care or health insurance environment.
Hands-on experience with:
- MCG (Milliman Care Guidelines)
- GuidingCare
- Facets
Proficient with Microsoft Office and working across multiple systems.

Preferred Qualifications

Critical Care or Emergency Room (ER) nursing experience.
Experience supporting Blue Cross Blue Shield or other health insurance plans.
Previous experience as a Utilization Management Specialist.

Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.

Numbers & Facts

Location

Baltimore, MD (

Remote)

Skills

Blueprintsunmatched
Business Processesunmatched
Business Strategyunmatched
Clinical Nursingunmatched
Consultingunmatched
Critical Careunmatched
Data Qualityunmatched
Documentation Reviewunmatched
Emergency Careunmatched
Enterprise Architectureunmatched
Health Insuranceunmatched
Healthcareunmatched
Healthcare Providersunmatched
Hospitalunmatched
Industry Standardsunmatched
Information Technology Consultingunmatched
Licensed Practical Nurse/Licensed Vocational Nurseunmatched
Managed Careunmatched
Medical Recordsunmatched
Microsoft Officeunmatched
Nursingunmatched
Nursing Credentialsunmatched
Patient Careunmatched
Professional Servicesunmatched
Registered Nurse (RN)unmatched
Technical Recruitingunmatched
Technical Supportunmatched
Time Managementunmatched
Utilization Managementunmatched

Level up your application

Professional resume templates

Browse dozens of recruiter approved resume templates, layouts and formats. Choose your favorite and make it your own in minutes.

Free resume templates

Resume Builder

Improve your existing resume or start from scratch and create a standout, ATS-friendly resume. Add job-specific content, download and apply.

Resume Builder