Utilization Review Specialist

Utilization Review Specialist – RN/LPN

Location: 100% Remote – U.S.
Work Hours: 8:00 AM – 5:00 PM ET, with 1-hour lunch
Contract: 3 months, with possible extensions
Schedule: Monday–Friday
Licensure: Maryland RN/LPN license or Compact State RN/LPN license

Job Description

We are looking an experienced Utilization Review Specialist (RN/LPN) to support a major healthcare payor in Maryland. The ideal candidate will have strong clinical nursing and utilization management experience, with demonstrated knowledge of Milliman Care Guidelines (MCG), GuidingCare (HealthEdge), and Facets.

The Utilization Review Specialist will perform prospective, concurrent, and retrospective utilization reviews to determine medical necessity, appropriateness of care, authorization, and benefit coverage. This role requires strong clinical judgment, critical-thinking skills, and the ability to analyze complex clinical information while applying medical policies, contracts, regulatory requirements, and evidence-based guidelines.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for medical and behavioral health services.
• Determine medical necessity and appropriateness of care using MCG, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program guidelines, medical policies, contracts, and regulatory requirements.
• Review clinical documentation and make appropriate authorization and benefit determinations.
• Research diseases, treatments, emerging technologies, and high-cost/high-dollar services to support recommendations to Medical Directors.
• Collaborate with Medical Directors, providers, Provider Contracting, Member Services, Sales/Marketing, and other internal teams.
• Assist with benefit determinations based on member contracts and applicable lines of business, including Commercial, Federal, and Medicare.
• Coordinate non-par provider/facility case-rate negotiations with providers, facilities, and Provider Contracting.
• Identify and facilitate appropriate referrals and alternative care settings when necessary.
• Communicate effectively with members, providers, healthcare professionals, and internal stakeholders.
• Research and present educational information related to clinical conditions, treatment modalities, and utilization management topics.
• Maintain compliance with NCQA standards, regulatory requirements, medical policies, departmental SOPs, and PHI/confidentiality requirements.

Required Qualifications

• Bachelor's degree in Nursing preferred/required.
• Active Maryland RN/LPN license OR Compact State RN/LPN license.
• Minimum 5 years of clinical nursing experience.
• Minimum 5 years of clinical utilization review/utilization management experience preferred.
• Strong experience with Milliman Care Guidelines (MCG) – required.
• Hands-on experience with GuidingCare (HealthEdge) – required.
• Experience with Facets – required.
• Working knowledge of managed care and healthcare delivery systems.
• Strong knowledge of clinical guidelines, medical policies, accreditation standards, and regulatory requirements.
• Strong clinical assessment and critical-thinking skills.
• Ability to conduct effective member/provider interactions by telephone.
• Strong written and verbal communication skills.
• Ability to work with large volumes of confidential member information and PHI.
• Proficiency with web-based applications and Microsoft Office (Word, Excel, PowerPoint).

Preferred Qualifications

• Critical Care/ICU experience.
• Emergency Room (ER) experience.
• Experience with Nasco.
• Previous experience with Blue Cross Blue Shield (BCBS) organizations, particularly BCBS of North Carolina.
• Experience supporting Commercial, Federal Employee Program, and Medicare populations.

Important Requirements

• 100% Remote – candidates may reside anywhere in the U.S.; California candidates are not preferred.
• U.S. Citizen or Green Card required.
• Maryland or Compact State RN/LPN license required.
• Rate is firm.
• Strong utilization review/clinical background is mandatory.
• Candidate must be a strong critical thinker with the ability to make timely, clinically sound decisions.
• MCG, GuidingCare/HealthEdge, and Facets are must-have technologies.