Utilization Review Nurse / RN for Medicaid - Remote
About The Position
Sentara Health Plans is hiring a Utilization Review Nurse/ RN for Medicaid. This is a full-time, permanent position with standard working hours of 8am to 5pm EST, Monday through Friday. Weekend and holiday coverage is required, with nurses participating in a self-scheduling process and expected to work 13 weekend day shifts per year, as well as assigned holiday coverage. Remote opportunities are available in multiple states. The role involves utilizing management services within the scope of licensure, conducting prior authorization, inpatient review, concurrent review, retrospective review, and managing medical director referrals. The nurse will be responsible for issuing approval and/or denial letters, reviewing provider requests, conducting pre-certification and continued stay reviews, and ensuring compliance with criteria, medical policy, and member eligibility. The position may also involve managing appeals and providing notification to members and providers. Proactive discharge planning and serving as a joint transition of care coordinator are key responsibilities. The nurse must ensure the medical director’s written decision aligns with established criteria and facilitate accreditation by understanding and applying regulatory requirements.
Requirements
- Registered Nurse (RN) License (Compact or Virginia) REQUIRED
- 3 years of acute care clinical experience REQUIRED
- Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Strong Microsoft skills (Word, Excel, Outlook and Teams).
Nice To Haves
- Bachelors Degree in Nursing preferred
- Previous Utilization Review highly preferred
- Previous LTSS Waiver OR Medicaid experience highly preferred
- InterQual or Milliman experience preferred.
- Knowledge of NCQA preferred.
Responsibilities
- 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.
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
- Pet Insurance
- Legal Resources Plan
- Annual discretionary bonus if established system and employee eligibility criteria is met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
