Remote Utilization Review Specialist (RN/LPN)

Ampcus Inc; Owings Mills (MD); Remote; USD 90,000 - 120,000; Full time

Job summary

Ampcus Inc. is seeking a Utilization Management Specialist (Remote) to review medical necessity and authorization for clinical services. The role emphasizes clinical nursing expertise, care management experience, and adherence to guidelines and policies.

The position requires knowledge of managed care, strong communication skills, and the ability to handle confidential PHI while coordinating with medical directors and other teams. Remote work is offered nationwide.

Qualifications

• Bachelor's Degree in Nursing or 4 years of relevant work experience in lieu of a degree.
• 5 years of clinical nursing experience and 2 years of care management experience.
• RN/LPN state licensing or compact.
• Working knowledge of managed care and health delivery systems.
• Effective written and interpersonal communication skills, strong assessment skills, and proficiency in web-based technology and Microsoft Office applications.
• Ability to work effectively with large amounts of confidential member data and PHI, prioritize workload, multitask, and maintain a dynamic personal organization system.

Responsibilities

• Determine medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, and guidelines to manage member assignments.
• Conduct research and analysis of pertinent diseases, treatments, and emerging technologies to support decisions and recommendations to medical directors. Collaborate with stakeholders to determine appropriate benefit application.
• Make appropriate referrals and contacts; assist members and providers for alternative settings for care; present educational topics to interdepartmental audiences.]

Skills

Clinical nursing experience

Care management experience

Written and interpersonalcommunication

Microsoft Office proficiency

Education

Bachelor's Degree in Nursing

4 years of relevant work experience in lieu of degree

Tools

Web-based technology

Microsoft Office

Job description

Ampcus Inc. is seeking a Utilization Management Specialist (Remote) to review medical necessity and authorization for clinical services. The role emphasizes clinical nursing expertise, care management experience, and adherence to guidelines and policies.

The position requires knowledge of managed care, strong communication skills, and the ability to handle confidential PHI while coordinating with medical directors and other teams. Remote work is offered nationwide.