Remote LPN/LVN Utilization Management Reviewer - Employelevate

Join our team at Sagility, a leading healthcare company that combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise. We are seeking a talented LPN/LVN Utilization Management Reviewer to join our team in a fully remote, work-from-home role. As a Utilization Management Reviewer, you will play a key role in ensuring that our clients receive the highest quality care while meeting CMS compliance standards.

In this exciting role, you will be responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities under the provisions of our client's benefits plan. You will conduct timely clinical decision reviews, apply established criteria, and employ your clinical expertise to interpret clinical criteria and determine medical necessity. You will also communicate results of reviews to primary care teams, specialty providers, vendors, and members, and provide decision-making guidance to clinical teams as needed.

We offer a competitive salary and a comprehensive benefits package, 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. If you are a motivated and experienced LPN/LVN with a strong skillset in utilization management, we encourage you to apply for this exciting opportunity.

Key Responsibilities:

• Conduct timely clinical decision reviews for services requiring prior authorization
• Apply established criteria and employ clinical expertise to determine medical necessity
• Communicate results of reviews to primary care teams, specialty providers, vendors, and members
• Provide decision-making guidance to clinical teams as needed
• Work closely with clinicians, medical staff, and peer reviewers to facilitate escalated reviews
• Ensure accurate documentation of clinical decisions and consistency in applying policy

Requirements:

• Associate degree and current, valid Massachusetts clinical license in good standing
• 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
• Ability to apply predetermined criteria to service decision requests to assess medical necessity
• Flexibility and understanding of individualized care plans
• Strong interpersonal, verbal, and written communication skills
• Ability to work independently and in a team-based environment

What We Offer:

• Competitive salary
• Comprehensive benefits package, including medical, dental, vision, life insurance, and more
• 401K with employer contribution
• PTO and sick time
• Tuition reimbursement
• Opportunity to work with a leading healthcare company

How to Apply:

To apply for this exciting opportunity, please click on the "Apply To This Job" button. We look forward to talking with you!

Sagility is an Equal Opportunity Employer/Vet/Disability.

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