Health Services

• Spec, Utilization Ampcus, Inc United States, Maryland, Baltimore Aug 26, 2026 Ampcus Inc.

is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team.

Position Overview Duration:

3

Months Location:

100%

Remote Work Schedule:

8:00 a.m.

• 5:00 p.

m. EST (flexible hours) Must-Have Qualifications Minimum 5 years of clinical nursing experience Background in critical care or managed care Prior knowledge of managed care and utilization review Proficiency with MCG guidelines Active compact RN license or Maryland RN license Strong knowledge of Microsoft applications Experience with both Facets and Guiding Care (mandatory) Preferred Qualifications LPN license is acceptable Purpose Utilizing key principles of utilization management, the Utilization Review Specialist 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 to contribute to the determination of appropriateness and authorization of clinical services both medical and behavioral health. Essential Functions 50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references. Follows NCQA Standards, Medical Policy, all guidelines, and departmental SOPs to manage member assignments. Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies. 30% 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. 20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level Bachelor's Degree 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. Preferred Qualifications Working knowledge of managed care and health delivery systems. Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards. Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment, and the ability to confidently use the internet as a resource. Knowledge, Skills and Abilities (KSAs) Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues. Must have strong assessment skills with the ability to make rapid connection with Member telephonically. Must be able to work effectively with large amounts of confidential member data and PHI. Must be able to prioritize workload during heavy workload periods. Ability to multitask, prioritize, and maintain a dynamic personal organization system that allows for flexibility. Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint. Excellent analytical and problem-solving skills to judge the appropriateness of member services and treatments on a case-by-case basis. Licenses/Certifications RN

• Registered Nurse
• State Licensure And/or Compact State Licensure Upon Hire Required LPN
• Licensed Practical Nurse
• State Licensure CNS-Clinical Nurse Specialist Preferred Additional Skills Clinical UM expertise, regulatory compliance knowledge, experience in Guiding care platform.

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.