Utilization Review Nurse

Overview

Sentara Health is looking to hire a Remote Utilization Review Nurse.

Remote opportunities are 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, West Virginia, Wisconsin, Wyoming.

City/State:
Norfolk, VA

Work Shift:

First (Days)

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.

• Associate’s degree required.
• Bachelor’s degree preferred.

• Registered Nurse required.

• Must possess 2-3 years of acute care clinical experience required.
• Previous Utilization Review experience a plus.
• Milliman and JIVA preferred.
• Knowledge of NCQA preferred.
• Accreditation & Regulatory 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.

• 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 are met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco‑free environment.

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.