Utilization Review Nurse, RN

Job not on LinkedIn

🔥 0 minutes ago

🏈 Alabama, Florida, +24 more states – Remote

🏈 Alabama – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote ❄️ Minnesota – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $66.8k - $111.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Sentara Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1890

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • 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

• Conduct prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and member/provider approval or denial letters • Review provider requests for services requiring authorization • Conduct pre-certification, continued stay review, care coordination, and discharge planning • Review treatment-setting appropriateness and compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts • Manage appeals for denied services • Provide written and verbal notifications to members and providers • Perform proactive anticipatory discharge planning • Serve as joint transition-of-care coordinator with case management and facilitate member care transitions • Ensure medical director decisions are consistent with CMS, state, medical policy, and clinical criteria • Facilitate accreditation by accurately applying accrediting and regulatory requirements and standards

🎯 Requirements

• 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, facilitation, and analytical skills • Strong Microsoft skills, including Word, Excel, Outlook, and Teams • Bachelor’s Degree in Nursing preferred • Availability for standard hours of 8am to 5pm EST, Monday through Friday • Weekend and holiday coverage required • Expected to work 13 weekend day shifts per year and assigned holiday coverage • Ability to work in one of the listed eligible states

🏖️ 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 • Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met • Market-competitive compensation packages inclusive of base pay, incentives, and benefits • Professional development and continued employment philosophy