Senior Utilization Review Specialist

🔥 0 minutes ago

🇺🇸 United States – Remote

⏱ Part Time

🟠 Senior

👻 Ghost score 18%

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Sage Clinical RCM, LLC

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2024

🏥 Healthcare

☁️ SaaS

🤝 B2B

Healthcare • SaaS • B2B

Sage Clinical RCM is a healthcare revenue cycle management company that combines proprietary technology with clinical and financial expertise to provide end-to-end RCM solutions—from patient access through financial close. The firm offers advisory services, revenue cycle management operations, technology adoption (including clinical documentation improvement and autonomous coding), workforce augmentation (coding, documentation, RCM, physician advisory), and analytics-driven platforms (Sage IQ: Validity and VERO) that use automation and AI to unify coding, documentation, vendor performance, compliance, and financial reporting for healthcare organizations.

📋 Description

• Perform concurrent and retrospective utilization review for assigned inpatient, observation, and outpatient cases • Apply InterQual, MCG, or client-approved criteria to support medical necessity, level of care, continued stay, and patient-status determinations • Obtain, submit, and track payer notifications and authorizations • Communicate clinically relevant information to payer medical-management teams within required time frames • Identify and escalate medical-necessity, authorization, status, and documentation risks • Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle partners • Coordinate clinical information and deadlines for peer-to-peer review or denial escalation • Maintain complete, accurate documentation in designated systems • Serve on the Utilization Review Committee and prepare reports on utilization trends, denial patterns, extended stays, and workflow barriers • Escalate patient-status-change compliance issues to UR Committee members and present outcomes • Provide guidance and support on complex review questions as a senior clinical resource • Participate in quality audits, education, process improvement, and utilization-management initiatives

🎯 Requirements

• Current, unrestricted RN license • Five or more years of acute-care hospital experience • At least three years in utilization review, utilization management, case management, or a closely related function • Demonstrated experience applying medical-necessity and level-of-care criteria, including concurrent review and continued-stay review • Working knowledge of inpatient versus observation status, payer authorization requirements, Medicare and managed-care utilization principles, and denial-prevention practices • Strong clinical judgment, prioritization, documentation, communication, and collaborative problem-solving skills • Ability to independently manage a high-volume, deadline-driven caseload while exercising sound judgment regarding escalation • Availability during agreed hospital business hours • Discretion with protected health information and strict compliance with HIPAA, client security standards, and applicable regulations

🏖️ Benefits

• Part-time employment • Fully remote work arrangement • Participation in required meetings and education • Process improvement and professional education initiatives