Utilization Review Nurse/ RN for Imaging/Commercial- Remote!

117 Sentara Workforce Solutions, LLC; Virginia; Hybrid; USD 67,000 - 111,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Adoption, Fertility and Surrogacy Reim

Paid Time Off and Sick Leave

Parental & Family Caregiver Leave

401k/403B with Employer Match

Tuition Assistance

Employee bonuses potential

Job summary

Sentara Health Plans is hiring a Utilization Review Nurse (RN) for Imaging/Commercial – Remote! This is a full-time, permanent position (40 hours) with 8am to 5pm EST, Mon-Fri, plus 13 weekend day shifts yearly and on-call holiday coverage. Remote opportunities are available in numerous states across the U.S.

Education: BSN preferred; RN license (Compact or Virginia). Preferred: 3 years acute care and prior utilization review or imaging experience.

Qualifications

• Bachelor's degree in Nursing preferred.
• Registered Nurse (RN) license required (Compact or Virginia).
• Experience in utilization review and imaging preferred.

Responsibilities

• Perform pre-certification, inpatient, concurrent, and retrospective reviews.
• Review provider requests for services requiring authorization.
• Coordinate discharge planning and transitions of care.
• Ensure compliance with CMS, state, and medical policy criteria.
• Assist with appeals for denied services.

Skills

Utilization review

Nurse RN

Pre-certification

Care coordination

Discharge planning

Inpatient review

CMS compliance

Education

Bachelor's degree in Nursing

Registered Nurse License (Compact or Virginia)

Tools

InterQual or Milliman

Job description

City/State Norfolk, VA Work Shift First (Days) Overview: Sentara Health Plans is hiring a Utilization Review Nurse/ RN for Imaging/Commercial- Remote! Status: Full-time, permanent position (40 hours) Standard working hours: 8am to 5pm EST, M-F. Weekend and holiday coverage required. Nurses participate in a self-scheduling process and are expected to work 13 weekend day shifts per year, as well as assigned holiday coverage. Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming.

Job responsibilities: Utilization Review Nurse is responsible for utilizing management services within the scope of licensure. Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conduct pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. May manage appeals for services denied. Responsible for written and/or verbal notification to members and providers. Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition. Ensures medical director’s 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: Bachelors Degree in Nursing preferred Certification/Licensure Registered Nurse (RN) License (Compact or Virginia)

Preferred qualifications: 3 years of acute care clinical experience Previous Utilization Review experence highly preferred Previous imaging experience preferred InterQual or Milliman experience preferred Knowledge of NCQA preferred Sentara Health Plans provides health plan coverage to close to one million members in Virginia.

Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health. We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $66,830.4 – $111,384. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth. Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

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!