RN Clinical Utilization Management Reviewer

Sagility India Private Ltd in; El Paso (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare service provider is seeking a Remote RN Clinical Utilization Management Reviewer. This role focuses on evaluating medical necessity and ensuring compliance with standards while collaborating with clinical teams for timely service authorizations. Ideal candidates will possess a Massachusetts RN license and demonstrate strong clinical experience in utilization management.

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

Qualifications

• 3+ years combined clinical and utilization management experience required.
• Experience in health plan and/or care management platform is a plus.
• Remote work experience preferred.

Responsibilities

• Evaluate medical necessity and appropriateness of healthcare services.
• Conduct timely clinical decision reviews for prior authorization.
• Work closely with clinical teams for service planning and documentation.

Skills

Ability to assess medical necessity

Strong interpersonal skills

Flexibility in care plans

Independent work ability

Education

Associates Degree

Bachelors Degree preferred

Massachusetts RN clinical license

Tools

Epic

InterQual

Job description

RN Clinical Utilization Management Reviewer (Finance)

About Sagility

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 Clinical Utilization Management Reviewer

Job Description:

We are currently hiring a RN - Utilization Management Reviewer. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of client?s benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The 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 have a current, valid Massachusetts clinical license in good standing.

Key responsibilities:???

• Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to inpatient hospital services
• Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
• Communicates 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 requirements
• Provides decision-making guidance to clinical teams on service planning as needed
• Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
• Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
• Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
• Creates and maintains database of denied service requests
• Additional duties as requested by supervisor
• Standard office conditions. Some travel to clinical practices may be required.

Education:??

• Associates Degree, Bachelors Degree preferred
• Massachusetts RN clinical license in good standing.

Experience:??

• Required: 3+ years combined clinical and utilization management experience
• Strong plus: 3+ years? experience working in a health plan and/or experience with a care management platform
• Experience with Epic preferred.
• Experience with remote work preferred
• Experience with InterQual preferred

Skills:??

• Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity
• Flexibility and understanding of individualized care plans
• Ability to influence decision making
• Strong interpersonal, verbal and written communication skills
• Ability to work independently
• Comfort working in a team-based environment
• Will be required to pass credentialing process.

Hourly wage: $35-40 pending experience

Hours: Monday through Friday 9AM to 5PM Eastern Time. Some weekends may be required

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??

??

Join our team, we look forward to talking with you!??

An Equal Opportunity Employer/Vet/Disability??

Location:

Work@Home USAUnited States of America