Company Description
Lumen Solutions Group Inc. is a technology consulting Services company based in Florida. We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, and Enterprise Transformation.
Role
Utilization Management Nurse Specialist
Location
100% Remote
Duration
3-Month Contract (Potential for Extension)
Job Description
We are seeking an experienced Utilization Management Nurse Specialist to support utilization review and care management activities within a managed care environment. The ideal candidate will have a strong clinical nursing background, experience with utilization management processes, and proficiency with industry-standard care management tools and guidelines.
Position Overview
- 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.
Required Qualifications
- 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.
Preferred 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.
Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.