RN Utilization Management Reviewer

We are currently hiring a talented RN, Utilization Management Reviewer.  This role will be responsible in day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must hold a valid, current license issued by the Massachusetts Board of Registration in Nursing.

Key responsibilities:   

• Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH)
• Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
• Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
• Provides decision-making guidance to clinical teams on service planning as needed
• Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
• Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
• Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
• Additional duties as requested by supervisor
• Maintains knowledge of CMS, State and NCQA regulatory requirements

Education Requirements:

• RN - Associate’s Degree required, Bachelor’s Degree preferred
• RN, current license issued by the Massachusetts Board of Registration in Nursing
• CCM (Certified Case Manager) a plus

Required Experience (must have):

• 1 to 2 years Utilization Management experience.
• 2 or more years working in a clinical setting 

Desired Experience (nice to have):

• 2 or more years of Home Health Care experience
• 2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

• Ability to complete assigned work in a timely and accurate manner
• Knowledge of the Utilization management process
• Ability to work independently

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity
• Flexibility and understanding of individualized care plans
• Ability to influence decision making
• Strong collaboration and negotiation skills
• Strong interpersonal, verbal, and written communication skills
• Comfort working in a team-based environment
• Knowledge of Medicare and Mass health services and benefits

Salary: $35.00 - $40.00 Hourly pending experience

Hours: Monday through Friday 9AM to 5:30PM Eastern Time. Some weekends may apply.

This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.

Sagility Offers Competitive Benefits Including:     

• Medical  
• Dental  
• Vision  
• Life Insurance  
• Short-Term and Long-Term Disability  
• Flexible Spending Account  
• Life Assistance Program  
• 401K with employer contribution  
• PTO and Sick Time  
• Tuition Reimbursement  

Join our team, we look forward to talking with you!  

An Equal Opportunity Employer/Vet/Disability