Status: Full-time, permanent position (40 hours)
Standard working hours: 8am to 5pm EST, M-F.
Location: Remote in Virginia.
Job responsibilities:
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.
Education:
BLD - Bachelor's Level Degree in Nursing preferred
Certification/License:
Registered Nurse License (RN) - Nursing License - Compact/Multi-State License
Experience:
Minimum 3 years of acute care clinical experience.
Previous Utilization Review and Case Management experience a plus.
Commercial Health Insurance experience 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.
Sentara Health Plans 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.
Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.
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.
Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.
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!
To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-92584
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Talroo - Nursing
Utilization Review Nurse, RN, BSN, InterQual, Milliman, NCQA, Remote, Virginia, Case Management, BSN, Bachelor's, Commercial, Health Plan, Health Insurance, Managed Care, MCO