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 ReviewerJob 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.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 servicesCommunicates 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 requirementsProvides decision-making guidance to clinical teams on service planning as neededWorks closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating ProceduresEnsures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policyWorks with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are metAdditional duties as requested by supervisorMaintains knowledge of CMS, State and NCQA regulatory requirementsEducation Requirements:RN - Associate’s Degree required, Bachelor’s Degree preferredRN, current license issued by the Massachusetts Board of Registration in NursingCCM (Certified Case Manager) a plusRequired 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 experience2 or more years working in a Medicare Advantage health PlanRequired Knowledge, Skills & Abilities (must have):Ability to complete assigned work in a timely and accurate mannerKnowledge of the Utilization management processAbility to work independentlyDesired 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 necessityFlexibility and understanding of individualized care plansAbility to influence decision makingStrong collaboration and negotiation skillsStrong interpersonal, verbal, and written communication skillsComfort working in a team-based environmentKnowledge of Medicare and Mass health services and benefitsSalary: $35.00 - $40.00 Hourly pending experience. Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekendsThis 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   Location:Work@Home USAUnited States of AmericaOriginally posted on Himalayas