Utilization Management Specialist (RN)

Utilization Management Specialist (RN)

Location: Baltimore, MD Type: Contract To Hire Compensation: Max BR $68 /hr, Mid-Range Pay (MRP) $100,500/yr Work Model: Remote offsite

Responsibilities

Perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care, and benefit coverage.

Analyze clinical information, contracts, mandates, medical policies, evidence-based research, and regulatory requirements to determine appropriateness and authorization of clinical services, both medical and behavioral health.

Reference regulatory mandates, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program, and other accepted medical/pharmaceutical references to determine medical necessity.

Conduct research on diseases, treatments, and emerging technologies, including high-cost/high-dollar services, to support decisions and recommendations to medical directors.

Collaborate with medical directors, provider relations, sales, marketing, and contracting teams to ensure appropriate benefit application and negotiate provider case rates.

Make referrals and contact members or providers for alternative care settings and present educational topics related to cases, diseases, and treatment modalities.

Document and communicate findings accurately and efficiently throughout the review process.

Requirements

5+ years of Clinical Nursing experience

2+ years of Utilization Management or Care Management experience

RN or LPN license; Compact license for MD required

Strong computer skills, including proficiency with Windows, PDFs, Excel, and healthcare management software

Knowledge of managed care, health delivery systems, and clinical guidelines such as CareFirst, NCQA standards, and accreditation requirements

Excellent written and interpersonal communication skills to engage with members, healthcare professionals, and internal teams

Ability to handle multiple cases daily and work independently

Nursing in Emergency or Critical Care preferred; Medicare/Medicaid and DSNIP knowledge strongly preferred

System One, and its subsidiaries including Joul and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.

System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.