Utilization Review Nurse - Remote (Select States)

City/State

Norfolk, VA

Overview

Work Shift

First (Days) (United States of America)

Sentara Health is currently seeking a full-time remote Utilization Review Nurse.

Position Status: Full-time, Day Shift

Standard Working Hours: Monday - Friday, 8:00AM to 5:00PM (EST)

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

For those located in Washington State and Maryland, the following salary range applies: $77,903.28 - $116,865.84

Job Requirements:

• RN Licensure Compact/Virginia Required

• Bachelor of Science in Nursing Preferred

• Acute Care - 3 years Required

• Previous experience in Accreditation and Regulatory Preferred

• Previous experience in Medicare Utilization Management Highly Preferred

Job Description Summary

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.

RN required; BSN preferred. Must possess 2-3 years of acute care clinical experience. Previous Utilization Review experience a plus. 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 Benefits:

Sentara employees strive to make our communities healthier places to live. We’re setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For more information about our employee benefits, https://www.sentaracareers.com/explore-sentara/benefits/

Join our team, where we are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, growth!

Job Summary

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.

RN required; BSN preferred. Must possess 2-3 years of acute care clinical experience. Previous Utilization Review experience a plus. 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.

Qualifications:

BLD - Bachelor's Level Degree

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Accreditation and Regulatory, Acute Care, Utilization Management

Skills

Communication, Complex Problem Solving, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Service Orientation

Sentara Healthcare 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.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission “to improve health every day,” this is a tobacco-free environment.