LPN/LVN Utilization Management Reviewer

We are currently hiring a LPN/LVN Utilization Management Reviewer. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of client’s benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The 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 have a current, valid Massachusetts clinical license in good standing.

Key responsibilities:   

• Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Durable Medical Equipment/Services, 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
• Creates and maintains database of denied service requests
• Additional duties as requested by supervisor
• Standard office conditions.  Some travel to clinical practices may be required.

Education:  

• Associate degree
• MA clinical license (Physical Therapy, Occupational Therapy, or Respiratory Therapist) in good standing.

Experience:  

• Required: 3+ years combined clinical and utilization management experience
• Strong plus: 3+ years’ experience working in a health plan and/or experience with a care management platform

Skills:   

• Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity
• Flexibility and understanding of individualized care plans
• Ability to influence decision making
• Strong interpersonal, verbal and written communication skills
• Ability to work independently
• Comfort working in a team-based environment
• Will be required to pass credentialing process.

Hourly pending experience

Hours: Monday through Friday 9AM to 5PM Eastern Time

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