Remote RN Utilization Management Reviewer

Sagility LLC; United States; Remote; USD 48,000 - 55,000; Full time

Benefits offered by this job

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

Job summary

Sagility LLC, a leader in healthcare transformation, seeks an RN Utilization Management Reviewer for a fully remote role. You will perform timely clinical decision reviews for services requiring prior authorization across various clinical areas, applying criteria like InterQual and clinical judgment to determine medical necessity.

Hours are Mon-Fri 9:00 AM–5:30 PM Eastern; compensation is hourly $35.00–$40.00, with standard benefits including medical, dental, vision, and 401(k).

Qualifications

• RN with 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.

Responsibilities

• Conduct timely clinical decision review for services requiring prior authorization in a variety of clinical areas.
• Apply established criteria (e.g., InterQual) to determine medical necessity.
• Communicate results of reviews verbally, in the medical record, and through written notification to teams, vendors, and members.
• Provide decision-making guidance to clinical teams on service planning as needed.
• Work closely with clinicians and reviewers to facilitate escalated reviews per SOPs.
• Ensure accurate documentation of clinical decisions and consistency in applying policy.
• Collaborate with UM Manager and leadership to meet policies and regulatory requirements.
• Maintain knowledge of CMS, state, and NCQA regulatory requirements.
• Perform additional duties as requested by supervisor.

Job description

Sagility LLC, a leader in healthcare transformation, seeks an RN Utilization Management Reviewer for a fully remote role. You will perform timely clinical decision reviews for services requiring prior authorization across various clinical areas, applying criteria like InterQual and clinical judgment to determine medical necessity.

Hours are Mon-Fri 9:00 AM–5:30 PM Eastern; compensation is hourly $35.00–$40.00, with standard benefits including medical, dental, vision, and 401(k).