About the role
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 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
Additional duties as requested by supervisor
Maintains knowledge of CMS, State and NCQA regulatory requirements
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
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