Job Description

City/State

Norfolk, VA

Work Shift

First (Days)

Sentara Health Plans is hiring an Utilization Review Nurse/RN- Remote in Virginia

Status: Full-time, permanent position (40 hours)

Standard working hours: 8am to 5pm EST, M-F

Location: Remote in Virginia

Job responsibilities:

• RN Clinician responsible for utilization 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.

• Conducts 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 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) REQUIRED

Preferred qualifications:

• 3 years of acute care clinical experience REQUIRED

• Previous Utilization Review highly preferred

• Previous LTSS Waiver OR Medicaid experience highly preferred

• InterQual or Milliman experience preferred.

• Knowledge of NCQA preferred.

• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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.

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!

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-99842

Talroo - Nursing

Utilization, Review, Registered Nurse, BSN, ADN, Nursing, Managed Care, MCO, Health Plan, Virginia, RN, VA, LTSS, Long Term Support Services, Medicaid,

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.