Utilization Review Nurse

Company Description
Lumen Solutions Group Inc. is a technology consulting Services company based in Florida. We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, Enterprise Transformation.

Role : Utilization Review Nurse
Location: Baltimore MD(Remote)
Type: Contract

Job Description:
We are seeking an experienced Utilization Review Nurse (LPN or RN) to support high-volume clinical reviews for commercial and FEP health plans. The ideal candidate will have strong utilization management and care management experience, expertise with MCG guidelines, and the ability to manage a fast-paced review environment while ensuring quality and compliance.

Must-Have Requirements

• Active and unrestricted LPN (Compact State License) or RN license .
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of care management and/or utilization review experience
• Strong experience performing:
  • Inpatient reviews
  • Inpatient admissions reviews
  • Surgical procedure reviews
  • Infertility reviews
  • Home health reviews
• Hands-on experience using MCG (Milliman Care Guidelines) - mandatory.
• Strong understanding of evidence-based clinical guidelines and medical necessity criteria.
• Ability to work in a high-volume production environment handling approximately 30-35 reviews per day.
• Strong documentation, communication, and critical-thinking skills.

Key Responsibilities

• Perform utilization and medical necessity reviews for inpatient admissions, surgeries, home health, infertility, and related services.
• Apply MCG guidelines to determine appropriate level of care and authorization decisions.
• Review clinical documentation to ensure compliance with payer policies and regulatory requirements.
• Maintain productivity and quality standards in a high-volume review environment.
• Collaborate with care management teams, providers, and internal stakeholders.
• Accurately document review outcomes and authorization determinations in the system.

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