Job Description

ALTA IT Services is staffing a contract to hire opportunity for a Utilization Management Nurse to support a leading health insurance customer. The UM Nurse 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.



Pay: $46/HR

90% Remote
May go onsite occasionally in Baltimore, MD 

Must have LPN/ RN- MD or compact 
Knowledge of Milliman Care Guidelines  


Duties:
Reviews authorization requests for initial determination and/or triages for clinical review and resolution.
Provides general support and coordination services for the department including but not limited to answering and responding to telephone calls, taking messages, letters and correspondence, researching information and assisting in solving problems.
Assists with reporting, data tracking, gathering, organization and dissemination of information such as Continuity of Care process and tracking of Peer to Peer reviews.
Performs member or provider related administrative support.




Qualifications
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or
LPN - Licensed Practical Nurse - State Licensure
Knowledeg of MCG- Milliman Care Guidelines 

#M2

Job Tags

Contract work,

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