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.

RN Utilization Management Reviewer

• Conduct timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including surgical procedures, Medicare Part B medications, LTSS, and Home Health.
• Apply established criteria (e.g., Inter Qual) and employ clinical expertise to interpret criteria to determine medical necessity.
• Communicate results of reviews verbally, in the medical record, and through written notification to primary care team, specialty providers, vendors, and members in adherence with regulatory and contractual requirements.
• Provide decision‑making guidance to clinical teams on service planning as needed.
• Work closely with clinicians, medical staff, and peer reviewers to facilitate escalated reviews in accordance with SOPs.
• Ensure accurate documentation of clinical decisions and work with UM Manager to ensure consistency in applying policy.
• Collaborate with UM Manager and other clinical leadership to ensure departmental and organizational policies and procedures as well as regulatory and contractual requirements are met.
• Maintain knowledge of CMS, state, and NCQA regulatory requirements.
• Perform additional duties as requested by supervisor.

• RN – Associate’s Degree required;
  Bachelor’s Degree preferred.
• Valid, current license issued by the Massachusetts Board of Registration in Nursing.
• 1 to 2 years of Utilization Management experience.
• 2 or more years working in a clinical setting.
• Certified Case Manager (CCM) a plus.
• Desired: 2+ years of Home Health Care experience; 2+ years working in a Medicare Advantage health plan.
• Must have knowledge of the Utilization Management process and ability to work independently.
• Must be able to complete assigned work in a timely and accurate manner.

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

Hourly: $35.00 - $40.00 (pending experience)

Hours:

Monday through Friday, 9:00 AM to 5:30 PM Eastern Time; may require weekends.

Location:

Fully remote work at home role. Secure, private area with hardwired internet connection speeds greater than 5MB upload and 10MB download required.

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

An Equal Opportunity Employer/Vet/Disability.