Utilization Review Nurse, Registered Nurse (RN) for LTSS Waiver, Medicaid

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🔥 6 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Sentara Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1890

⚕️ Healthcare Insurance

Healthcare Insurance

Sentara Health is a leading healthcare system that operates over 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals. The company is dedicated to providing exceptional patient care, fostering professional development, and maintaining a diverse workforce. Sentara Health aims to improve health every day and has been recognized for its clinical and operational performance, being named one of the top 15 health systems by IBM Watson Health. The organization supports its employees in achieving their full potential and encourages growth and innovation in the healthcare sector.

📋 Description

• 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.

🎯 Requirements

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

🏖️ 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 • Reimbursement for certifications and free access to complete CEUs and professional development • Pet Insurance • Legal Resources Plan • Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.