Utilization Review Nurse/ RN for Imaging/Commercial- Remote!

About the position Sentara Health Plans is hiring a full-time, permanent Utilization Review Nurse for Imaging/Commercial. This remote role is available to candidates residing in the listed eligible states. The position is 40 hours per week, with standard hours of 8 a.m. to 5 p.m. Eastern Time, Monday through Friday. Weekend and holiday coverage is required; nurses self-schedule and are expected to work 13 weekend day shifts per year, in addition to assigned holiday coverage. The nurse performs utilization management services within the scope of licensure. The role reviews requests for services requiring authorization and supports prior authorization, inpatient and concurrent review, retrospective review, medical director referrals, and member/provider approval or denial notifications. Reviews assess appropriate treatment settings and compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts. The nurse may manage appeals, coordinates care transitions and discharge planning, and ensures medical director decisions are consistent with applicable criteria and regulatory requirements. Sentara Health Plans provides coverage to close to one million members in Virginia through commercial, Individual and Family, Medicare, and Medicaid plans, as well as Employee Assistance Programs. Its services include a broad provider network, chronic illness support, wellness programs, and integrated clinical and behavioral health services. Sentara describes its culture as family-friendly and supportive of community involvement, development, and growth. It is an equal opportunity employer and maintains a tobacco-free environment.

Responsibilities

• Perform utilization management services within the scope of licensure.
• Conduct prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and approval or denial letter processes for members and providers.
• Review provider requests for services requiring authorization.
• Conduct pre-certification, continued stay review, care coordination, and discharge planning or treatment-setting appropriateness reviews.
• Ensure reviews comply with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Manage appeals for services that have been denied, as applicable.
• Provide written and/or verbal notifications to members and providers.
• Anticipate discharge planning needs, coordinate transitions of care jointly with case management, and facilitate member care transitions.
• Ensure medical directors’ written decisions are consistent with CMS, state, medical policy, and clinical criteria.
• Support accreditation by understanding, interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

• Registered Nurse (RN) license, compact or Virginia, required.
• Three years of acute care clinical experience required.

Nice-to-haves

• Bachelor’s degree in Nursing preferred.
• Previous utilization review experience highly preferred.
• Previous imaging experience preferred.
• InterQual or Milliman experience preferred.
• Knowledge of NCQA preferred.

Benefits

• Medical, dental, and vision plans.
• Adoption, fertility, and surrogacy reimbursement up to \$10,000.
• Paid time off and sick leave.
• Paid parental and family caregiver leave.
• Emergency backup care.
• Long-term and short-term disability and critical illness plans.
• Life insurance.
• 401(k)/403(b) with employer match.
• Tuition assistance up to \$5,250 per year and discounted educational opportunities through Guild Education.
• Student debt pay down up to \$10,000.
• Pet insurance.
• Legal resources plan.
• Opportunity to earn an annual discretionary bonus, subject to system and employee eligibility criteria.
• Paid holidays.
• Educational assistance or student loan repayment.