Utilization Management Specialist
About the role
In this role, you’ll use your clinical background and utilization management experience to review requests for care and determine medical necessity, appropriateness, and benefit coverage. You’ll work fully remote and leverage MCG, medical policy, and regulatory guidelines while collaborating with Medical Directors and internal teams to support timely, accurate authorization decisions.
Responsibilities
- Perform prospective, concurrent, and retrospective utilization reviews (medical + behavioral health).
- Make medical necessity / appropriateness determinations and support prior authorizations.
- Use clinical criteria and policy resources daily (including MCG / Milliman Care Guidelines).
- Review clinical documentation, benefits, and mandates to ensure services align with coverage and guidelines.
- Research diagnoses/treatments and high-cost services; summarize findings and escalate complex cases to Medical Directors as needed.
- Collaborate with internal partners and providers to support benefit application and appropriate levels/settings of care.
- Maintain accurate documentation and protect PHI while managing a busy caseload.
Requirements
- Active RN or LPN license (RN preferred) — Maryland compact/eligibility required
- 5+ years clinical nursing experience
- 2+ years care management / utilization management experience
- MCG experience (required)
- Experience supporting Commercial/FEP/Medicare lines of business and applying medical policy/regulatory standards
- Strong critical thinking, written communication, and ability to work independently in a remote setting
- Comfortable with web-based tools + Microsoft Office (Word/Excel/PowerPoint)
- Guiding Care and FACETS (required)
Qualifications
- Nice to have:
- Critical Care or ER clinical background
- Experience with LCD/NCD, Medicare guidelines, ASAM, or other authorization criteria sets
Skills
- System One, and its subsidiaries including Joulé and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America.
Benefits
- System One offers eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.
Pay
Pay (W2): USD 51.00/Hour
Schedule
Schedule: Mon–Fri, 8:00am–5:00pm ET (1-hour lunch) - Flex after ramp-up start time between 7:00am–9:00am ET
Company Information
System One and its subsidiaries including Joulé and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.
EEO Statement
System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law. #M-1 Ref: #851-Rockville-S1