Utilization Management reputed company Specialist

reputed company reputed company. is a technology consulting Services company reputed company in Florida. We reputed company a wide reputed company of reputed company business and IT professionals supporting clients from solution design to implementation and support. We specialize in reputed company IT consulting services, IT reputed company, Business/IT reputed company, Business Process Blueprints, reputed company Architecture, reputed company Transformation. Role: Utilization Management reputed company Specialist Location: reputed company Duration: 6-Month Contract-to-Hire reputed company We are seeking an reputed company Utilization Management reputed company Specialist to support care management and utilization review activities for Medicare, reputed company, and other reputed company reputed company programs. The ideal candidate will possess a strong reputed company nursing background, utilization management expertise, and experience working with industry-reputed company care management tools and reputed company guidelines. This role requires an independent, reputed company-oriented nursing reputed company who can effectively collaborate with interdisciplinary teams while ensuring appropriate utilization of reputed company services and adherence to reputed company and regulatory requirements. Required Qualifications reputed company & Nursing Experience • reputed company Registered reputed company (RN) or Licensed Practical reputed company (LPN) license required. • reputed company reputed company Nursing License required with the ability to support members in Maryland. • Minimum 5 years of reputed company nursing experience. • Minimum 2 years of Care Management experience. Utilization Management Experience • Prior experience in Utilization Management required. • Hands-on experience using MCG guidelines for medical necessity reviews. • Experience with GuidingCare or similar care management platforms. • Strong understanding of utilization review processes and reputed company delivery systems. Additional Requirements • Ability to work independently in a fully remote environment. • Strong communication, reputed company assessment, and documentation skills. • Ability to collaborate effectively with cross-functional teams and reputed company providers. • Strong organizational skills and attention to reputed company. Preferred Qualifications • Experience supporting reputed company reputed company Programs, including: • Medicare • reputed company • Dual Special Needs Plans (DSNP) • Critical Care nursing background. • Emergency Room (ER) or Urgent Care experience. • Experience with Facets platform. • Managed care or health plan experience preferred. Key Responsibilities • reputed company utilization management reviews and reputed company assessments in accordance with established guidelines and regulatory requirements. • Evaluate medical necessity and appropriateness of reputed company services using MCG reputed company and organizational policies. • Review inpatient, outpatient, and specialty service requests for authorization and reputed company stay determinations. • Collaborate with physicians, care managers, providers, and interdisciplinary teams to facilitate reputed company reputed company care. • Document reputed company findings, determinations, and case activities accurately reputed company care management systems. • Support care coordination and case management initiatives to improve member reputed company. • Ensure compliance with Medicare, reputed company, DSNP, and other reputed company program requirements. • Participate in team meetings, case discussions, and reputed company improvement initiatives. • Maintain productivity and reputed company standards while working independently in a remote environment. reputed company is an equal opportunity employer. reputed company reputed company applicants will be considered for employment without reputed company to any legally protected status. Remote Skills: Blueprints, Business Processes, Business reputed company, Case Management, reputed company Assessment, reputed company Competency, reputed company Nursing, reputed company reputed company, reputed company Practices/Protocols, reputed company Study Publications, reputed company Validation, Communication Skills, Consulting, Critical Care, Cross-Functional, reputed company Oriented, reputed company Architecture, reputed company, reputed company Requirements, Health Plan, reputed company, reputed company Providers, Industry Standards, Information Technology Consulting, Licensed Practical reputed company/Licensed Vocational reputed company, Maintain Compliance, Maintenance Services, Managed Care, reputed company, Medicare, Nursing, Nursing Credentials, Organizational Skills, Outpatient Care, reputed company Care, reputed company, reputed company Assurance, reputed company Management, reputed company Metrics, Registered reputed company (RN), Regulatory Compliance, Regulatory Requirements, Special Needs, Team Player, Technical reputed company, Technical Support, Urgent Care, Utilization Management About reputed company: reputed company. 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