Job Description
Role Description
- Sentara Health is looking to hire a Remote Utilization Review Nurse. This is a remote position available in multiple states.
- 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 letters.
- Reviews provider requests for services requiring authorization.
- Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
- Ensures 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.
- Qualifications
- Associates degree required; Bachelor's degree preferred.
- Registered Nurse certification required.
- 2-3 years of acute care clinical experience required.
- Previous Utilization Review experience a plus.
- Knowledge of Milliman and JIVA preferred.
- Knowledge of NCQA preferred.
- Knowledge of Accreditation & Regulatory preferred.
- Strong oral, written, and interpersonal communication skills.
- Problem-solving, facilitation, and analytical skills.
- Strong Microsoft skills (Word, Excel, Outlook, and Teams).
- Requirements
- Must be flexible to work on rotating weekends including holidays.
- 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
- Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria are met.
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