Clinical Utilization Review & Care Optimization Specialist

Ampcus, Inc; Baltimore (MD); On-site; USD 80,000 - 120,000; Full time

Job summary

Ampcus, Inc in Baltimore, MD seeks a Utilization Review Specialist to perform prospective, concurrent and retrospective reviews for authorization and benefit coverage, ensuring compliance with regulatory standards and payer guidelines. The role requires nursing expertise, 5+ years of clinical nursing with 2 years in care management, plus knowledge of NCQA standards and Medicare guidelines.

Responsibilities include researching evidence-based guidelines, applying policies, and communicating

Qualifications

• Bachelor's degree in nursing and active RN license or equivalent.
• Minimum 5 years of clinical nursing experience with 2 years in care management.
• Knowledge of NCQA standards, Medicare guidelines and regulatory compliance.

Responsibilities

• Abstracts medical necessity and determines appropriateness using guidelines and contracts.
• Researches diseases, treatments, and emerging therapies to support decisions.
• Coordinates referrals, discusses options with providers and members as needed.

Skills

Effective communication

Interpersonal skills

PHI handling

Time management

Multitasking

Microsoft Office

Education

Bachelor's degree in Nursing

RN license

LPN license

CNS certification

Job description

Ampcus, Inc in Baltimore, MD seeks a Utilization Review Specialist to perform prospective, concurrent and retrospective reviews for authorization and benefit coverage, ensuring compliance with regulatory standards and payer guidelines. The role requires nursing expertise, 5+ years of clinical nursing with 2 years in care management, plus knowledge of NCQA standards and Medicare guidelines.

Responsibilities include researching evidence-based guidelines, applying policies, and communicating