Utilization Management Nurse Specialist

Company Description
Lumen SolutionsGroupInc. is a technology consulting Services company based inFlorida. Weprovidea wide array of experienced business and IT professionals supporting clients from solution design to implementation and specialize in professional IT consulting services IT Staffing Business/IT Strategy Business Process Blueprints Enterprise Architecture and EnterpriseTransformation.

Role : Utilization Management Nurse Specialist
Location: 100% Remote
Duration: 3-Month Contract (Potential for Extension)

Job Description:
We are seeking an experienced Utilization Management Nurse Specialist to support utilization review and care management activities within a managed care environment. The ideal candidate will have a strong clinical nursing background experience with utilization management processes and proficiency with industry-standard care management tools and guidelines.

Position Overview

• Review medical records and evaluate the medical necessity of healthcare services.
• Apply MCG (Milliman Care Guidelines) to make utilization management decisions.
• Perform utilization review and care management activities in accordance with payer policies.
• Collaborate with physicians hospitals and healthcare providers to coordinate patient care.
• Document reviews and maintain accurate case information using GuidingCare and Facets .
• Manage multiple applications while ensuring timely and accurate case processing.

Required Qualifications

• Active RN (preferred) or LPN license with a Maryland or Compact Nursing License .
• Minimum 5 years of clinical nursing experience .
• Minimum 2 years of Care Management experience.
• Previous Utilization Management or Utilization Review experience in a managed care or health insurance environment.
• Hands-on experience with:
  • MCG (Milliman Care Guidelines)
  • GuidingCare
  • Facets
• Proficient with Microsoft Office and working across multiple systems.

Preferred Qualifications

• Critical Care or Emergency Room (ER) nursing experience.
• Experience supporting Blue Cross Blue Shield or other health insurance plans.
• Previous experience as a Utilization Management Specialist.

Lumen SolutionsGroup Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.

Required Experience:

IC