[Hiring] Utilization Review Nurse / RN for Medicaid @Sentara Health

Role Description

Sentara Health Plans is hiring a Utilization Review Nurse/ RN for Medicaid - 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

Job responsibilities:

• 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
• 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

• Bachelors Degree in Nursing (preferred)
• Registered Nurse (RN) License (Compact or Virginia) - REQUIRED
• 3 years of acute care clinical experience - REQUIRED
• Previous Utilization Review - highly preferred
• Previous LTSS Waiver OR Medicaid experience - highly preferred
• InterQual or Milliman experience - preferred
• Knowledge of NCQA - preferred
• Strong oral, written and interpersonal communication skills
• Problem-solving skills, facilitation skills, and analytical skills
• Strong Microsoft skills (Word, Excel, Outlook and Teams)

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
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met