UTILIZATION REVIEW NURSE

Sentara Health

4d • Remote

About The Position

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.

Requirements

• Registered Nurse (required)
• 3 years of acute care clinical experience (required)
• Microsoft suite (Word, Excel, Outlook)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Nice To Haves

• BSN (preferred)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)

Responsibilities

• 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.

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
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level