Utilization Review Specialist

ALTA IT Services is staffing a contract to hire opportunity for a Utilization Management Specialist to support a leading health insurance customer. The individual 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: $47.75/HR Hybrid- Baltimore, MD Must have one of the following: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req LPN - Licensed Practical Nurse - State Licensure CNS-Clinical Nurse Specialist Duties: Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, 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.) 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. Education Details: Nursing Experience: 5 years Clinical nursing experience 2 years Care Management In Lieu of Education In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. #M2 Ref: #855-IT Baltimore