Utilization Management Nurse Specialist

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, Enterprise Transformation.

Role: Utilization Management Nurse Specialist

Location: 100% Remote

Duration: 6-Month Contract-to-Hire

Position Overview

We are seeking an experienced Utilization Management Nurse Specialist to support care management and utilization review activities for Medicare, Medicaid, and other government healthcare programs. The ideal candidate will possess a strong clinical nursing background, utilization management expertise, and experience working with industry-standard care management tools and clinical guidelines.

This role requires an independent, detail-oriented nursing professional who can effectively collaborate with interdisciplinary teams while ensuring appropriate utilization of healthcare services and adherence to clinical and regulatory requirements.

Required Qualifications

Clinical & Nursing Experience

• Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license required.
• Active Compact Nursing License required with the ability to support members in Maryland.
• Minimum 5 years of clinical nursing experience.
• Minimum 2 years of Care Management experience.
  
  

Utilization Management Experience

• Prior experience in Utilization Management required.
• Hands-on experience using MCG guidelines for medical necessity reviews.
• Experience with GuidingCare or similar care management platforms.
• Strong understanding of utilization review processes and healthcare delivery systems.
  
  

Additional Requirements

• Ability to work independently in a fully remote environment.
• Strong communication, clinical assessment, and documentation skills.
• Ability to collaborate effectively with cross-functional teams and healthcare providers.
• Strong organizational skills and attention to detail.
  
  

Preferred Qualifications

• Experience supporting Government Healthcare Programs, including:
• Medicare
• Medicaid
• Dual Special Needs Plans (DSNP)
• Critical Care nursing background.
• Emergency Room (ER) or Urgent Care experience.
• Experience with Facets platform.
• Managed care or health plan experience preferred.
  
  

Key Responsibilities

• Perform utilization management reviews and clinical assessments in accordance with established guidelines and regulatory requirements.
• Evaluate medical necessity and appropriateness of healthcare services using MCG criteria and organizational policies.
• Review inpatient, outpatient, and specialty service requests for authorization and continued stay determinations.
• Collaborate with physicians, care managers, providers, and interdisciplinary teams to facilitate quality patient care.
• Document clinical findings, determinations, and case activities accurately within care management systems.
• Support care coordination and case management initiatives to improve member outcomes.
• Ensure compliance with Medicare, Medicaid, DSNP, and other government program requirements.
• Participate in team meetings, case discussions, and quality improvement initiatives.
• Maintain productivity and quality standards while working independently in a remote environment.
  
  

Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.