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.

Job title:

UM Licensed Vocational Nurse

Job Description:

The Utilization Management LVN supports the UM team by conducting medical necessity reviews, coordinating authorizations, and ensuring appropriate utilization of healthcare services in accordance with established guidelines. This role requires strong clinical judgment, attention to detail, and excellent communication skills to effectively collaborate with providers, members, and internal teams.

Responsibilities:

Conduct prospective, concurrent, and retrospective reviews to determine medical necessity and appropriateness of care
Apply established criteria such as MCG or InterQual to assess clinical documentation
Assist with processing prior authorization requests and determining level of care
Collaborate with RNs, physicians, and other clinical staff to ensure coordinated, timely reviews
Communicate determinations to providers and members in a timely and professional manner
Maintain accurate documentation of clinical reviews, determinations, and communications in the system
Identify and escalate cases that do not meet criteria to the appropriate clinical reviewer
Ensure compliance with regulatory and accreditation standards including NCQA, CMS, and state-specific guidelines
Participate in team meetings, trainings, and audits to ensure quality and consistency
Support special projects or initiatives as assigned by leadership

Qualifications:

Active and unrestricted LVN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges
3+ years of Nursing experience
1+ years of Utilization Management experience
Familiarity with medical terminology, utilization management guidelines, and clinical documentation standards
Proficiency in Microsoft Office and experience working with healthcare systems or electronic medical records
Strong organizational and time management skills with the ability to work independently
Excellent written and verbal communication skills

Compensation Highlights