Terms of Employment • Contract, 12 Months • This position is 100% remote following the onsite training period in the Canton neighborhood of Baltimore, MD. Training typically lasts seven (7) business days. Therefore, candidates must reside in Maryland.
Overview & Responsibilities • Our client, a leading healthcare organization, is seeking two experienced Utilization Management Nurse Specialists to support the implementation of new state mandates effective January 1, 2025. These positions focus on managing members within Maryland's risk jurisdiction and ensuring compliance with Milliman Care Guidelines (MCG).
As a Utilization Management Nurse Specialist, you will: • Review medical documentation submitted by providers and facilities, compare it to MCG guidelines, and determine if cases meet criteria for approval. • Escalate cases that do not meet guidelines to the Medical Director for further evaluation. • Communicate case determinations, including approvals or denials, to providers or facilities professionally and in a timely manner. • Manage the denial process for non-compliant cases, ensuring all procedures adhere to state and organizational policies. • Utilize care management workflow software to document and track case activities and outcomes. • Stay informed about evolving state mandates and guidelines to ensure accurate case management.
Required Skills & Experience • Active Registered Nurse (RN) license in Maryland with a compact license. • At least 5 years of RN experience, including: • 3+ years in clinical practice. • 2+ years in utilization management. • Strong proficiency in Milliman Care Guidelines (MCG) and care management workflows. • Exceptional communication and organizational skills to handle high caseloads effectively. • Strong detail-orientation and collaborative skills with the ability to manage multiple cases and maintain strong communication with healthcare providers and facilities.
Preferred Skills & Experience • Experience with HealthEdge GuidingCare. • Familiarity with healthcare systems such as NASCO and Facets.