Utilization Management Nurse Specialist

Lumen Solutions Group Inc. is a Florida-based technology consulting services company providing experienced business and IT professionals to support clients from solution design through implementation and support. We specialize in professional IT consulting, IT staffing, business/IT strategy, business process blueprints, enterprise architecture, and enterprise transformation.

About the role

We are seeking an experienced Utilization Management Nurse Specialist to support utilization review and care management activities within a managed care environment. This is a 100% remote, 3-month contract position with potential for extension.

Responsibilities

• Review medical records and evaluate the medical necessity of healthcare services.
• Apply MCG (Milliman Care Guidelines) to make utilization management decisions.
• Perform utilization review and care management activities in accordance with payer policies.
• Collaborate with physicians, hospitals, and healthcare providers to coordinate patient care.
• Document reviews and maintain accurate case information using GuidingCare and Facets.
• Manage multiple applications while ensuring timely and accurate case processing.

Requirements

• Active RN (preferred) or LPN license with a Maryland or Compact Nursing License.
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of Care Management experience.
• Previous Utilization Management or Utilization Review experience in a managed care or health insurance environment.
• Hands-on experience with:
  • MCG (Milliman Care Guidelines)
  • GuidingCare
  • Facets
• Proficient with Microsoft Office and working across multiple systems.

Qualifications

• Critical Care or Emergency Room (ER) nursing experience.
• Experience supporting Blue Cross Blue Shield or other health insurance plans.
• Previous experience as a Utilization Management Specialist.