Elite Technical is seeking a Maryland or Nurse Licensure Compact (NLC) certified (RN or LPN) Utilization Review Specialist to support our customer, a major Healthcare payor in the Maryland area. We are seeking candidates who has 5 years as a Nurse, 2 years in a Utilization Management role, and has understanding of Milliman Care Guidelines (MCG) and Guidingcare/Healthedge.

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.

Although this position is fully remote, we are seeking candidates that reside in the following states: DC, MD, VA, WV, NC, PA, DE, NY, NJ, TX, FL.

Required Skills

Required:
- Education Level: Bachelor's Degree. Education Details: Nursing
- Maryland Issued or compact license (Nurse Licensure Compact or NLC) LPN or RN Nurse
- Experience: 5 years Clinical nursing experience, 2+ years in Utilization Review/Utilization Management
- 2 years Care Management (Critical care and/or ER is highly preferred)
- Milliman Care Guidelines (MCG) knowledge is required
- Guidingcare (Healthedge) platform experience is required
- 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

Preferred:
-Medicare/Medicaid/DNSIPS - Highly highly preferred
- Facets
- Nasco experience
- Working knowledge of managed care and health delivery systems.