[Hiring] Utilization Review Nurse @Sentara Health

Role Description

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 and care coordination for appropriateness of treatment.
• Sets 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.

Qualifications

• BSN (preferred)
• Registered Nurse (required)

Requirements

• 3 years of acute care clinical experience (required)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Benefits

• Market-competitive compensation packages, inclusive of base pay, incentives, and benefits.
• Base pay range for full-time employment is $93,184.00 - $136,947.20 annually.
• Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities.
• Comprehensive benefits package, including medical, dental, vision, life and disability insurance.
• 401(k)/403(b) with employer match.
• Paid time off (vacation, sick time, and holidays).
• Paid parental and military leave.
• Educational assistance or student loan repayment.
• Voluntary benefits.
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000.
• Emergency Backup Care.
• Long-Term, Short-Term Disability, and Critical Illness plans.
• Life Insurance.
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education.
• Student Debt Pay Down – $10,000.
• Pet Insurance.
• Legal Resources Plan.
• Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.