Job Description

Utilization Review Specialist

Elite Technical is seeking a Maryland certified (RN or Clinical Nurse Specialist) Utilization Review Specialist to support new Maryland mandates coming in 2025. We are seeking candidates who has 5 years as a RN, 3 years in a Utilization Management role, and has understanding of Milliman Care Guidelines (MCG).

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent 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, contracts, 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, contracts, benefit information, Milliman Care Guidelines, Apollo 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, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, Client Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all lines of business to include Commercial, 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 decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts 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 related to cases, disease entities, treatment modalities to interdepartmental audiences.

Required Skills

-Required Certification: Maryland certified only: RN (Registered Nurse) or CNS (Clinical Nurse Specialist)
- Experience: 5 years Clinical nursing experience. 3 years as a Utilization Review Specialist
-Must have knowledge of Milliman Care Guidelines (MCG)
-Must have Guidecare (Healthedge) platform experience or similar
-Big Plus: Facets or Nasco 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, healthcare professionals, and internal colleagues
-Must have strong assessment skills with the ability to make rapid connection with Member telephonically.
-Must be able to work effectively with large amounts of confidential member data and PHI
-Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint

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Job Tags

Contract work,

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