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.

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.

• 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

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

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

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

• Ability to 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 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

• 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

Work@Home USAUnited States of America