Utilization Review Specialist (Maryland, USA)

Position Summary: We are seeking a detail-oriented Utilization Reviewer to join our team. This role is responsible for performing utilization review to authorize services for individuals enrolled in Medicaid. The ideal candidate will have documentation review experience and a Certified Nursing Assistant (CNA) background. This position involves applying program policies, verifying eligibility, and reviewing medical records to issue decisions regarding pre-authorization of services. Key Responsibilities: Conduct prospective reviews and issue review decisions based on established criteria (60%) Refer cases that do not meet criteria to a Registered Nurse or Social Worker reviewer (20%) Document medical information and maintain accurate records in the workflow system (10%) Respond to inquiries from providers and consumers, ensuring excellent customer service (5%) Perform miscellaneous duties as assigned (5%) Required Qualifications: High school diploma or equivalent Certified Nursing Assistant (CNA) background Experience reviewing and analyzing medical documentation 2 years of experience in a customer service or healthcare environment 1 year of experience in evaluating and researching healthcare services, policies, and programs Ability to handle confidential information in a deadline-driven environment Strong written and verbal communication skills Intermediate PC skills, including navigating electronic health records Preferred Qualifications: Experience in utilization review, insurance, or managed care Knowledge of home and community-based services Completion of a medical terminology course Work Environment & Physical Demands: Remote role after completion of 3-6 weeks of hybrid training in Columbia, Maryland Must be a Maryland resident Prolonged sitting and computer use required Benefits & Compensation: Salary: USD $23 per hour Benefits: Paid vacation, 401K, and Health Insurance If you meet the qualifications and are looking for a rewarding career in healthcare utilization review, apply today! Job Type: Full-time Pay: $22.00 - $23.00 per hour Expected hours: 40 per week Benefits: 401(k) Health insurance Paid time off Schedule: 8 hour shift Work Location: Remote