[Hiring] Utilization Review Nurse @Sentara Health
Role Description
Sentara Health is looking to hire a Remote Utilization Review Nurse. This is a remote position available in multiple states.
• 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 letters.
• Reviews provider requests for services requiring authorization.
• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
• Ensures 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.
Qualifications
• Associates degree required; Bachelor's degree preferred.
• Registered Nurse certification required.
• 2-3 years of acute care clinical experience required.
• Previous Utilization Review experience a plus.
• Knowledge of Milliman and JIVA preferred.
• Knowledge of NCQA preferred.
• Knowledge of Accreditation & Regulatory preferred.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving, facilitation, and analytical skills.
• Strong Microsoft skills (Word, Excel, Outlook, and Teams).
Requirements
• Must be flexible to work on rotating weekends including holidays.
Benefits
• 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
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria are met.
Apply tot his job
Apply To this Job
Sentara Health is looking to hire a Remote Utilization Review Nurse. This is a remote position available in multiple states.
• 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 letters.
• Reviews provider requests for services requiring authorization.
• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
• Ensures 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.
Qualifications
• Associates degree required; Bachelor's degree preferred.
• Registered Nurse certification required.
• 2-3 years of acute care clinical experience required.
• Previous Utilization Review experience a plus.
• Knowledge of Milliman and JIVA preferred.
• Knowledge of NCQA preferred.
• Knowledge of Accreditation & Regulatory preferred.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving, facilitation, and analytical skills.
• Strong Microsoft skills (Word, Excel, Outlook, and Teams).
Requirements
• Must be flexible to work on rotating weekends including holidays.
Benefits
• 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
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria are met.
Apply tot his job
Apply To this Job