UTILIZATION REVIEW NURSE

Sentara Health; Columbia (SC); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical plans

Dental plans

Vision plans

Adoption reimbursement

Fertility reimbursement

Surrogacy reimbursement

Paid Time Off

Parental leave

Family care leave

Emergency backup care

Disability insurance

Life Insurance

401k match

Tuition assistance

Student debt pay down

Pet Insurance

Legal resources plan

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to provide utilization management services under licensure. Duties include prior authorization, retrospective review, care coordination, and execution of member/provider approvals or denials with adherence to CMS and state criteria.

The role requires RN licensure, BSN preferred, and at least 3 years of acute care experience, with preferred familiarity in Milliman, NCQA, and Microsoft Office tools.

Qualifications

• RN license required.
• BSN preferred.
• 3 years of acute care clinical experience required.
• Experience with Utilization Review preferred.
• Familiarity with Milliman, NCQA, and CMS criteria preferred.

Responsibilities

• Perform utilization management services including prior authorization and pre-certification.
• Review requests for services requiring authorization and coordinate care for appropriateness of treatment.
• Notify members and providers of decisions in writing or verbally.
• Ensure decisions align with CMS, state, medical policy and criteria; support accreditation efforts.

Skills

Oral & Written Communication

Interpersonal skills

Analytical skills

Problem solving

Facilitation

Education

BSN

Tools

Microsoft Office

Job description

City/State: Norfolk, VA

Work Shift: First (Days)

Overview

Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse. The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, 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, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Responsible for written and/or verbal notification to members and providers. 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.

Education

• BSN (preferred)

Certification

• Registered Nurse (required)

Experience

• 3 years of acute care clinical experience (required)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Keywords

• Talroo- Health
• Utilization Review Nurse
• RN
• Care Coordination
• Discharge Planning
• Case Management
• Milliman
• NCQA

Compensation

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $93,184.00 - $136,947.20 annually. Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.

Benefits: Caring For Your Family and Your Career

• 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
• Pet Insurance
• Legal Resources Plan

Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer

and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco-free environment.

For positions that are available as remote work,

Sentara Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.