RN Utilization Management Reviewer

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries. Job title: RN Utilization Management Reviewer Job Description: 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. 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. May require weekends 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 An Equal Opportunity Employer/Vet/Disability Location: View email address on click.appcast.io USAUnited States of America #J-18808-Ljbffr Sagility