City/State

Work Shift

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.

Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming 

Job responsibilities:

• Utilization Review Nurse is 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. Conduct 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’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.

Education:

• Bachelors Degree in Nursing preferred

Certification/Licensure

• Registered Nurse (RN) License (Compact or Virginia) REQUIRED

Preferred qualifications:

• 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.

• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

• Strong Microsoft skills (Word, Excel, Outlook and Teams).

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $66,830.4 – $111,384.  Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities 

Benefits: Caring For Your Family and Your Career

• 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.

For positions that are available as remote work, Sentara Health employs associates in the following states:

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.