UTILIZATION REVIEW NURSE

Sentara Health; United States; Remote; USD 75,000 - 110,000; 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

Disability plans

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 is seeking a Utilization Review Nurse to support utilization management, prior authorization, retrospective review, and care coordination for appropriate treatment decisions. Candidates must hold an RN license with at least 3 years of acute care experience; BSN preferred.

Milliman and NCQA knowledge are a plus, with strong communication and analytical skills essential for success.

Qualifications

• Must hold an RN license with 3 years of acute care experience.
• BSN preferred.
• Milliman and NCQA knowledge is a plus.
• Proficient in MS Office and strong communication skills.

Responsibilities

• Perform prior authorization, retrospective review, and care coordination.
• Assess requests for services requiring authorization and ensure policy compliance.
• Provide written and verbal notifications to members and providers.

Skills

Utilization review

Care coordination

Communication skills

Problem-solving

Education

BSN (preferred)

RN licensure (required)

Tools

Microsoft Word

Excel

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, 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 ifestablished 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.