RN Utilization Management Reviewer
New
S
SagilityHealthcare
United States, Monday through Friday 9AM to 5:30PM Eastern TimeFull-TimeMiddle
Salary35 - 40 USD per hour
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Job Details
- Experience
- 1 to 2 years Utilization Management experience; 2 or more years working in a clinical setting
Requirements
- Valid, current Registered Nurse (RN) license issued by the Massachusetts Board of Registration in Nursing.
- Associate’s Degree in Nursing (Bachelor’s preferred).
- 1 to 2 years of Utilization Management experience.
- 2 or more years of experience working in a clinical setting.
- Knowledge of the Utilization Management process.
- Ability to complete assigned work in a timely and accurate manner.
- Ability to work independently.
- Secure, private work-at-home area.
- Hardwired internet connection with speeds greater than 5MB upload and 10MB download.
Responsibilities
- Conduct timely clinical decision review for services requiring prior authorization including surgical procedures, Medicare Part B medications, LTSS, and Home Health.
- Apply established criteria such as InterQual and clinical expertise to determine the medical necessity of services.
- Communicate review results verbally, in medical records, and via official written notification to primary care teams, providers, and members.
- Provide decision-making guidance to clinical teams on service planning.
- Collaborate with clinicians, medical staff, and peer reviewers to facilitate escalated reviews per Standard Operating Procedures.
- Ensure accurate documentation of clinical decisions and maintain consistency in policy application.
- Maintain up-to-date knowledge of CMS, State, and NCQA regulatory requirements.
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