UTILIZATION REVIEW NURSE

Sentara Health; Philadelphia (Philadelphia County); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid Time Off

Job summary

Sentara Health Plans Community Care seeks a dedicated Utilization Review Nurse in Norfolk, VA. You will manage prior authorization, retrospective review, pre-certification, and care coordination to ensure appropriate treatment and adherence to medical policy and contracts.

Requires RN license with BSN preferred; 3 years acute care experience and familiarity with Milliman, NCQA, and MS Office are advantageous. Competitive compensation and benefits offered.

Qualifications

• BSN (preferred).
• 3 years of acute care clinical experience (required).
• Prior Utilization Review experience (preferred).
• Milliman experience (preferred).
• Knowledge of NCQA (preferred).
• Microsoft Office (Word, Excel, Outlook) (preferred).
• Strong oral, written and interpersonal communication, problem-solving, facilitation and analytical skills.

Responsibilities

• Perform utilization management services including prior authorization, retrospective review, and pre-certification.
• Coordinate care and review services for appropriateness of treatment, ensuring compliance with criteria and policy.
• Provide written or verbal notification to members and providers and align decisions with medical policy and contracts.

Skills

Acute care experience

Utilization review

Communication skills

Problem solving

Interpersonal skills

Education

BSN (preferred)

Tools

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)
• 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.