Remote RN Utilization Management Specialist

System One; Baltimore (MD); On-site; USD 86,000 - 116,000; Full time

Job summary

System One in Baltimore, MD is seeking an experienced Utilization Management Specialist (RN) for a contract-to-hire engagement. The role focuses on reviewing authorizations and ensuring appropriate care and coverage for medical and behavioral health services, with a remote offsite work model.

The candidate will analyze clinical information against guidelines, collaborate with medical directors and service teams, and document findings clearly to support high-quality decision making.

Qualifications

• 5+ years of clinical nursing experience.
• 2+ years of utilization management or care management experience.
• RN or LPN license; Compact license for MD required.
• Strong computer skills including Windows, PDFs, Excel, and healthcare management software.
• Knowledge of managed care, health delivery systems, and clinical guidelines such as CareFirst, NCQA standards, and accreditation requirements.
• Excellent written and interpersonal communication skills to engage with members, healthcare professionals, and internal teams.
• Ability to handle multiple cases daily and work independently.
• Nursing in Emergency or Critical Care preferred; Medicare/Medicaid and DSNIP knowledge strongly preferred.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care, and benefit coverage.
• Analyze clinical information, contracts, mandates, medical policies, evidence-based research, and regulatory requirements to determine appropriateness and authorization of clinical services, both medical and behavioral health.
• Reference regulatory mandates, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program, and other accepted medical/pharmaceutical references to determine medical necessity.
• Conduct research on diseases, treatments, and emerging technologies, including high-cost/high-dollar services, to support decisions and recommendations to medical directors.
• Collaborate with medical directors, provider relations, sales, marketing, and contracting teams to ensure appropriate benefit application and negotiate provider case rates.
• Make referrals and contact members or providers for alternative care settings and present educational topics related to cases, diseases, and treatment modalities.
• Document and communicate findings accurately and efficiently throughout the review process.

Skills

Clinical nursing

Utilization management

RN licensure

Compact MD license

Windows

Excel

Healthcare software

Education

RN/LPN license; Compact MD

Tools

Windows

Excel

Healthcare management software

Job description

System One in Baltimore, MD is seeking an experienced Utilization Management Specialist (RN) for a contract-to-hire engagement. The role focuses on reviewing authorizations and ensuring appropriate care and coverage for medical and behavioral health services, with a remote offsite work model.

The candidate will analyze clinical information against guidelines, collaborate with medical directors and service teams, and document findings clearly to support high-quality decision making.