Utilization Review Nurse

Sentara Hospitals•Norfolk, VA

1d•Remote

About The Position

Sentara Health is looking to hire a Remote Utilization Review Nurse. This is a remote position: 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 Must be flexible to work on rotating weekends including holidays. 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.

Requirements

Associates required. Bachelors preferred.
Registered Nurse required.
Must possess 2-3 years of acute care clinical experience required.
Requires 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

Previous Utilization Review experience a plus.
Milliman and JIVA preferred.
Knowledge of NCQA preferred.
Accreditation & Regulatory 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
Reimbursement for certifications and free access to complete CEUs and professional development
Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.