Utilization Management reputed company Specialist

reputed company reputed company. is a technology consulting Services company based in Florida. We reputed company a wide reputed company of reputed company business and IT professionals supporting clients from solution design to implementation and support. We specialize in reputed company IT consulting services, IT reputed company, Business/IT reputed company, Business Process Blueprints, reputed company Architecture, reputed company Transformation. Role: Utilization Management reputed company Specialist Location: 100% Remote Duration: 6-Month Contract-to-Hire Position reputed company We are seeking an reputed company Utilization Management reputed company Specialist to support care management and utilization review activities for Medicare, reputed company, and other government reputed company programs. The ideal candidate will possess a strong clinical nursing background, utilization management expertise, and experience working with industry-reputed company care management tools and clinical guidelines. This role requires an independent, detail-oriented nursing reputed company who can effectively collaborate with interdisciplinary teams while ensuring appropriate utilization of reputed company services and adherence to clinical and regulatory requirements.

Required Qualifications

Clinical & Nursing Experience

• reputed company Registered reputed company (RN) or Licensed Practical reputed company (LPN) license required.
• reputed company Compact Nursing License required with the ability to support members in Maryland.
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of Care Management experience.

Utilization Management Experience

• Prior experience in Utilization Management required.
• Hands-on experience using MCG guidelines for medical necessity reviews.
• Experience with GuidingCare or similar care management platforms.
• Strong understanding of utilization review processes and reputed company delivery systems.

Additional Requirements

• Ability to work independently in a fully remote environment.
• Strong communication, clinical assessment, and documentation skills.
• Ability to collaborate effectively with cross-functional teams and reputed company providers.
• Strong organizational skills and attention to detail.

Preferred Qualifications

• Experience supporting Government reputed company Programs, including:
• Medicare
• reputed company
• Dual Special Needs Plans (DSNP)
• Critical Care nursing background.
• Emergency Room (ER) or Urgent Care experience.
• Experience with Facets platform.
• Managed care or health plan experience preferred.

Key Responsibilities

• reputed company utilization management reviews and clinical assessments in accordance with established guidelines and regulatory requirements.
• Evaluate medical necessity and appropriateness of reputed company services using MCG reputed company and organizational policies.
• Review inpatient, outpatient, and specialty service requests for authorization and reputed company stay determinations.
• Collaborate with physicians, care managers, providers, and interdisciplinary teams to facilitate reputed company patient care.
• Document clinical findings, determinations, and case activities accurately reputed company care management systems.
• Support care coordination and case management initiatives to improve member reputed company.
• Ensure compliance with Medicare, reputed company, DSNP, and other government program requirements.
• Participate in team meetings, case discussions, and reputed company improvement initiatives.
• Maintain productivity and reputed company standards while working independently in a remote environment.

reputed company is an equal opportunity employer. reputed company reputed company applicants will be considered for employment without reputed company to any legally protected status. Remote Skills: Blueprints, Business Processes, Business reputed company, Case Management, Clinical Assessment, Clinical Competency, Clinical Nursing, Clinical reputed company, Clinical Practices/Protocols, Clinical Study Publications, Clinical Validation, Communication Skills, Consulting, Critical Care, Cross-Functional, Detail Oriented, reputed company Architecture, Government, Government Requirements, Health Plan, reputed company, reputed company Providers, Industry Standards, Information Technology Consulting, Licensed Practical reputed company/Licensed Vocational reputed company, Maintain Compliance, Maintenance Services, Managed Care, reputed company, Medicare, Nursing, Nursing Credentials, Organizational Skills, Outpatient Care, Patient Care, reputed company Services, reputed company Assurance, reputed company Management, reputed company Metrics, Registered reputed company (RN), Regulatory Compliance, Regulatory Requirements, Special Needs, Team Player, Technical reputed company, Technical Support, Urgent Care, Utilization Management About reputed company: reputed company. Apply tot his job Apply To this Job