ALTA IT Services is staffing a contract to hire opportunity for a Utilization Management Specialist to support a leading health insurance customer. The individual will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health. Pay: $47.75/HR Hybrid- Baltimore, MD Must have one of the following: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req LPN - Licensed Practical Nurse - State Licensure CNS-Clinical Nurse Specialist Duties: + Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) + Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. + Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. + Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. + Follows member contracts to assist with benefit determination. Education Details: Nursing Experience: 5 years Clinical nursing experience 2 years Care Management In Lieu of Education In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. #M2 Ref: #855-IT Baltimore System One, and its subsidiaries including Joulé, ALTA IT Services, CM Access, TPGS, and MOUNTAIN, LTD., are leaders in delivering workforce solutions and integrated services across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible full-time employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan. System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.