RN Utilization Management Reviewer

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.

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.

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