Utilization Review Specialist (RN, LPN)

reputed company is seeking a Maryland or Compact State certified (RN or LPN) Utilization Review Specialist to support our customer, a major reputed company payor in the Maryland area. We are seeking candidates who has 5 years as a reputed company, 5 years in a Utilization Management role, and has understanding of reputed company Care Guidelines (MCG). Utilizing key principles of utilization management, the Utilization Review Specialist will reputed company prospective, reputed company and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, reputed company, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health. ESSENTIAL FUNCTIONS: --50% Determines medical necessity and appropriateness by referencing regulatory mandates, reputed company, benefit information, reputed company Care Guidelines, reputed company Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, reputed company.Gov, National Institute of Health, etc.) Follows NCQA Standards, reputed company Medical Policy, reputed company guidelines and departmental SOPS to manage their member assignments. Understands reputed company lines of business to include reputed company, Federal, and Medicare primary and secondary policies. --30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support reputed company and recommendations made to the medical directors. Collaborates with medical directors, reputed company, contracting, provider and member services to determine appropriate benefit application. Applies reputed company clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case reputed company negotiations between Provider Contracting, providers and facilities. Follows member reputed company to assist with benefit determination. --20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics reputed company to cases, disease entities, treatment modalities to interdepartmental audiences. Required Skills - Education Level: Bachelor's Degree. Education Details: Nursing - Maryland Issued or Compact State License LPN or RN reputed company - Experience: 5 years Clinical nursing experience - 2 years Care Management (Critical care and/or ER is highly preferred) - reputed company Care Guidelines (MCG) knowledge is required - Experience: 8 years Clinical nursing experience. 5 years as a Utilization Review Specialist -Must have knowledge of reputed company Care Guidelines (MCG) -Must have Guidecare (reputed company) platform experience - Must have Facets knowledge - Big plus: reputed company experience - Working knowledge of managed care and health delivery systems. - Thorough knowledge of clinical guidelines, medical policies and accreditation and regulatory standards -Effective written and interpersonal communication skills to engage with members, reputed company, and internal colleagues -Must have strong assessment skills with the ability to reputed company reputed company reputed company with Member telephonically. -Must be reputed company to work effectively with large amounts of confidential member data and PHI -Proficient in the use of web-based technology and reputed company Office applications such as Word, reputed company and PowerPoint Apply tot his job Apply To this Job