RN Utilization Management Reviewer

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

Benefits offered by this job

Medical

Dental

Vision

Life Insurance

Short-Term Disability

Long-Term Disability

Flexible Spending Account

Life Assistance Program

401K with employer contribution

PTO and Sick Time

Tuition Reimbursement

Job summary

Sagility is hiring an RN Utilization Management Reviewer to perform day-to-day clinical and service authorization reviews for medical necessity, ensuring CMS compliance in decision-making.

Requires RN license in Massachusetts, Associate degree minimum (Bachelor's preferred), 1–2 years in Utilization Management and 2+ years in a clinical setting; CCM a plus.

This fully remote US-based role offers competitive benefits, M-F 9:00–5:30 ET, and a salary of $35–$40 hourly, with potential weekend shifts.

Qualifications

• RN with an associate degree required; bachelor’s degree preferred.
• Current RN license issued by the Massachusetts Board of Registration in Nursing.
• CCM certification is a plus.

Responsibilities

• Perform day-to-day timely clinical and service authorization reviews for medical necessity and decision-making.
• Ensure CMS compliance standards in service decisions and organizational determinations.

Skills

Nursing license

Utilization management

Clinical experience

Home health care

Medicare Advantage

Independence

InterQual

Education

RN Associate's Degree

RN license (Massachusetts)

CCM certification (a plus)

Tools

InterQual

Medical Necessity Guidelines

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. Sagility has more than 25,000 employees across 5 countries.

Job title:

RN Utilization Management Reviewer

Job 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.

Education Requirements:

• 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

Required 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 experience
• 2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

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

Desired 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 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

Salary: $35.00 - $40.00 Hourly pending experience

Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekends

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

An Equal Opportunity Employer/Vet/Disability

Location:

Work@Home USAUnited States of America