[Hiring] Utilization Review Nurse/Registered Nurse (RN) @Sentara Health

Auto Import

Role Description

Sentara Health Plans is hiring a Utilization Review Nurse/RN- Remote in Virginia.

  • RN Clinician responsible for utilization management services within the scope of licensure.
  • Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and execution of member/provider approval and/or denial letter.
  • Reviews provider requests for services requiring authorization.
  • Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • May manage appeals for services denied.
  • Responsible for written and/or verbal notification to members and providers.
  • Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition.
  • Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria).
  • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Qualifications

  • Bachelors Degree in Nursing preferred.
  • Registered Nurse (RN) License (Compact or Virginia) REQUIRED.
  • 3 years of acute care clinical experience REQUIRED.
  • Previous Utilization Review highly preferred.
  • Previous LTSS Waiver OR Medicaid experience highly preferred.
  • InterQual or Milliman experience preferred.
  • Knowledge of NCQA preferred.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Benefits

  • Medical, Dental, Vision plans.
  • Adoption, Fertility and Surrogacy Reimbursement up to $10,000.
  • Paid Time Off and Sick Leave.
  • Paid Parental & Family Caregiver Leave.
  • Emergency Backup Care.
  • Long-Term, Short-Term Disability, and Critical Illness plans.
  • Life Insurance.
  • 401k/403B with Employer Match.
  • Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education.
  • Student Debt Pay Down – $10,000.
  • Reimbursement for certifications and free access to complete CEUs and professional development.
  • Pet Insurance.
  • Legal Resources Plan.
  • Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Back to blog