UTILIZATION REVIEW NURSE

Sentara Health Administration, Inc.; Norfolk (VA); On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Adoption reimbursement up to $10,000

PTO & Sick Leave

Parental & Family Caregiver Leave

Long/Short-term Disability

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse in Norfolk, VA. The role conducts utilization management, including prior authorization, retrospective review, and care coordination to ensure treatment aligns with policy and criteria.

The ideal candidate holds RN licensure with a BSN preferred, and has 3 years of acute care experience. Milliman and MS Office skills are advantageous in this role.

Qualifications

• 3 years of acute care clinical experience required.
• Previous Utilization Review experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office suite (Word, Excel, Outlook) preferred.

Responsibilities

• Perform utilization management services including pre-certification and prior authorization.
• Coordinate care coordination for appropriate treatment and criteria compliance.
• Review requests requiring authorization and communicate decisions to members/providers.
• Ensure adherence to CMS, state, and clinical policy criteria.

Skills

Oral communication

Written communication

Interpersonal skills

Problem-solving

Analytical skills

Facilitation skills

Education

RN licensure

BSN preferred

Tools

Microsoft Excel

Milliman

Job description

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, NCQABenefits: 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.