Sentara Health Plans is hiring a Utilization Review Nurse/ RN for Imaging/Commercial- Remote!

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

Standard working hours: 8am to 5pm EST, M-F. Weekend and holiday coverage required. Nurses participate in a self-scheduling process and are expected to work 13 weekend day shifts per year, as well as assigned holiday coverage.

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 

Job responsibilities:

• 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.

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 experence highly preferred

• Previous imaging experience preferred

• InterQual or Milliman experience preferred.

• Knowledge of NCQA preferred

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.

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $66,830.4 – $111,384.  Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities 

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-104599

Talroo - Nursing

Utilization, Review, Registered Nurse, BSN, ADN, Nursing, Managed Care, MCO, Health Plan, Virginia, RN, VA, Imaging, Commercial, North Carolina, 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 (state), West Virginia, Wisconsin, Wyoming