Full time
JR-40019

City/State

Virginia Beach, VA

Overview

Work Shift

First (Days) (United States of America)

Sentara Health Plans is currently hiring Utilization Review Nurse for our Commercial Hospital Review Team!

Sign on Bonus Available for qualified applicants!

This is a Full Time position with day shift hours and great benefits!

Remote opportunities available in the following states:

Virginia, North Carolina, Florida, Nevada, Wyoming, South Dakota, Washington, Indiana, Georgia, South Carolina, Tennessee, Texas, West Virginia, Wisconsin, Maryland, Alabama, Delaware, Idaho, Kansas, Louisiana, Maine, Minnesota, Nebraska, New Hampshire, North Dakota, Oklahoma, Pennsylvania, Ohio

Required Qualifications:

• RN License (Virginia)
• Associates or Bachelors Degree in Nursing
• Minimum 3 years experience working as a Registered Nurse in Acute Care
• Minimum 2 years experience in Behavioral Health

Preferred Qualifications:

• Utilization or Authorization experience

Job responsibilities:

• Responsible for utilization 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 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 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.

Sentara Health Plans is the health insurance division of Sentara Healthcare doing business as Optima Health and Virginia Premier.

Sentara Health Plans provides health insurance coverage through a full suite of commercial products including consumer-driven, employee-owned and employer-sponsored plans, individual and family health plans, employee assistance plans and plans serving Medicare and Medicaid enrollees.

With more than 30 years’ experience in the insurance business and 20 years’ experience serving Medicaid populations, 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.

Benefits: Sentara offers an attractive array of full-time benefits to include Medical, Dental, Vision, Paid Time Off, Sick, Tuition Reimbursement, a 401k/403B , 401a, Performance Plus Bonus, Career Advancement Opportunities, Work Perks and more.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.

Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family’s well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

For applicants within Washington State, the following hiring range will be applied: $77,903.28(annually) to $116,865.84(annually).

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!

Keywords: Nursing, Case management, Utilization Review, Authorization, UR Nurse, Commercial Hospital Review

Job Summary

RN Clinician responsible for utilization 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 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 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.

RN required; BSN preferred. Must possess 2-3 years of acute care clinical experience. Previous Utilization Review experience a plus. InterQual or Milliman experience preferred. Knowledge of NCQA preferred. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Qualifications:

BLD – Bachelor’s Level Degree

Registered Nurse License (RN) – Compact/Multi-State License, Registered Nurse License (RN) – North Carolina, Registered Nurse License (RN) – Virginia

Accreditation and Regulatory, Acute Care, Utilization Management

Skills

Communication, Complex Problem Solving, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Service Orientation

Sentara Healthcare 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.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission “to improve health every day,” this is a tobacco-free environment.