UTILIZATION REVIEW NURSE

Sentara Health; Norfolk (VA); In loco; USD 93.000 - 137.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical insurance

Dental insurance

Vision insurance

401k match

Paid time off

Parental leave

Student loan repayment

Tuition assistance

Pet insurance

Life insurance

Disability insurance

Annual bonus

Descrizione del lavoro

Sentara Health Plans Community Care seeks a Utilization Review Nurse (RN) in Norfolk, VA. The role supports utilization management, including prior authorization, pre-certification, and care coordination to ensure treatment aligns with medical policy and member contracts.

Required RN licensure with 3 years of acute care experience; BSN preferred. Milliman and NCQA knowledge are pluses; strong communication and analytical skills are essential.

Competenze

• RN license required
• 3 years of acute care clinical experience required
• Milliman experience preferred
• Knowledge of NCQA preferred
• Microsoft Suite experience preferred

Mansioni

• Perform utilization management including prior authorization and retrospective review
• Coordinate care, ensure treatment aligns with criteria and policy
• Prepare and communicate approvals or denials to members/providers
• Ensure compliance with accrediting and regulatory requirements

Conoscenze

Communication skills

Problem-solving

Facilitation

Analytical skills

Formazione

BSN preferred

Strumenti

Microsoft Word

Microsoft Excel

Microsoft Outlook

Descrizione del lavoro

City/StateNorfolk, VAWork ShiftFirst (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 skillsKeywords: Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQAWe 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. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.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.