UTILIZATION REVIEW NURSE

Sentara Health Plans; Norfolk, Northern (VA, KY); Hybrid; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Adoption, Fertility and Surrogacy Reim

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Emergency Backup Care

Long-Term, Short-Term Disability, and

Life Insurance

401k/403B with Employer Match

Tuition Assistance – $5,250/year

Student Debt Pay Down – $10,000

Pet Insurance

Legal Resources Plan

Job summary

Sentara Health Plans Community Care in Norfolk, VA seeks an Utilization Review Nurse to manage utilization management within licensure. You will handle prior authorization, retrospective review, and pre-certification while coordinating care and communicating decisions to members and providers.

The role requires a RN license, 3 years of acute care experience, and familiarity with Milliman and NCQA standards.

Qualifications

• BSN preferred.
• RN certification required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Word, Excel, and Outlook experience preferred.

Responsibilities

• Utilization management services within licensure.
• Perform prior authorization, retrospective review, and referrals.
• Review provider requests requiring authorization and issuance of decisions.
• Conduct pre-certification and care coordination for treatment appropriateness.
• Ensure reviews comply with criteria, policy, and member contracts.
• Notify members and providers in writing or verbally.
• Ensure medical director decisions align with CMS/state/clinical criteria and standards.

Skills

Prior authorization

Care coordination

Discharge planning

Case management

Microsoft suite knowledge

Education

BSN (preferred)

Registered Nurse (required)

Tools

Milliman

NCQA knowledge

Microsoft Word

Microsoft Excel

Microsoft Outlook

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)

Keywords

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

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.

Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan.

The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!