Commercial Utilization Review Nurse/RN- Remote ...

<p style="text-align:left"><u><b>City/State</b></u></p>Norfolk, VA<p style="text-align:inherit"></p><p style="text-align:left"><u><b>Work Shift</b></u></p>First (Days)<p style="text-align:inherit"></p><p style="text-align:left"><b>Overview:</b></p><h1><i><b>Sentara Health is currently hiring for a Utilization Review Nurse- Remote in VA!</b></i></h1><p></p><p><b>Status: <span style="overflow-wrap: break-word; display: inline; text-decoration: inherit; hyphens: auto;">Full-time, permanent</span> position (40 hours)</b></p><p></p><p><b>Standard working hours: 8am to 5pm EST, M-F.</b></p><p></p><p><b>Location: Remote in Virginia.</b></p><p><b>Job responsibilities:</b></p><ul><li><p>RN Clinician responsible for utilization management services within the scope of licensure.</p></li><li><p>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.</p></li><li><p>Reviews provider requests for services requiring authorization.</p></li><li><p>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.</p></li><li><p>May manage appeals for services denied.</p></li><li><p>Responsible for written and/or verbal notification to members and providers.</p></li><li><p>Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition.</p></li><li><p>Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria).</p></li><li><p>Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.</p></li></ul><p></p><p><b>Education:</b></p><ul><li><p>BLD - Bachelor's Level Degree in Nursing preferred</p></li></ul><p></p><p><b><span style="overflow-wrap: break-word; display: inline; text-decoration: inherit; hyphens: auto;">Certification/License:</span></b></p><ul><li><p>Registered Nurse License (RN) - Nursing License - Compact/Multi-State License</p></li></ul><p></p><p><b>Experience: </b></p><ul><li><p>Minimum 3 years of acute care clinical experience.</p></li><li><p>Previous Utilization Review and Case Management experience a plus.</p></li><li><p>Commercial Health Insurance experience preferred</p></li><li><p>InterQual or Milliman experience preferred.</p></li><li><p>Knowledge of NCQA preferred.</p></li><li><p>Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</p></li></ul><p></p><p></p><p><b>Sentara Health Plans</b> 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.</p><p></p><p>Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.</p><p></p><p>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.</p><p></p><p><i>Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.</i></p><p></p><p><b>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!</b></p><p></p><p><b>To apply, please go to </b><a href="http://www.sentaracareers.com/" target="_blank" rel="noopener noreferrer"><b><span style="overflow-wrap: break-word; display: inline; text-decoration: inherit; hyphens: auto;">www.sentaracareers.com</span></b></a><b> and use the following as your Keyword Search: JR-92584</b></p><p></p><p>#Indeed</p><p>Talroo - Nursing</p><p>Utilization Review Nurse, RN, BSN, InterQual, Milliman, NCQA, Remote, Virginia, Case Management, BSN, Bachelor's, Commercial, Health Plan, Health Insurance, Managed Care, MCO<span> </span></p><p style="text-align:inherit"></p><div><div><b>Benefits: Caring For Your Family and Your Career</b></div><div><b>• </b><span>Medical, Dental, Vision plans</span></div><div><span>• Adoption, Fertility and Surrogacy Reimbursement up to $10,000</span></div><div><span>• Paid Time Off and Sick Leave</span></div><div><span>• Paid Parental & Family Caregiver Leave </span></div><div><span>• Emergency Backup Care</span></div><div><span>• Long-Term, Short-Term Disability, and Critical Illness plans</span></div><div><span>• Life Insurance</span></div><div><span>• 401k/403B with Employer Match</span></div><div><span>• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education</span></div><div><span>• Student Debt Pay Down – $10,000</span></div><div><span>• Reimbursement for certifications and free access to complete CEUs and professional development</span></div><div><span>•Pet Insurance <br>•Legal Resources Plan<br>•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.</span></div><div></div></div><p style="text-align:inherit"></p><p style="text-align:left"><b>Sentara Health is an equal opportunity employer</b> and <span>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.</span></p><p style="text-align:left"><br>In support of our mission “to improve health every day,” this is a tobacco-free environment.</p><p style="text-align:inherit"></p><p style="text-align:left"><b><span>For positions that are available as remote work,</span></b><span> </span><b>Sentara Health employs associates in the following states:</b></p><p style="text-align:left"><span>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, West Virginia, Wisconsin, and Wyoming.</span></p>