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 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.

Job Title

RN Utilization Management Reviewer

Responsibilities

• 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., InterQual) 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.

Qualifications

• 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.

Desired Knowledge, Skills & Abilities

• Apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) 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.

Salary & Hours

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.

Benefits

• 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.