UTILIZATION REVIEW NURSE

Overview

Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse. The Utilization Review Nurse is responsible for utilization management services within the scope of licensure.

Responsibilities

• Conducts primary functions of prior authorization, 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, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Responsible for written and/or verbal notification to members and providers.
• 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

• Registered Nurse (required)
• 3 years of acute care clinical experience (required)

Qualifications

• BSN (preferred)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)

Skills

• Requires strong oral, written and interpersonal communication skills
• Problem-solving skills
• Facilitation skills
• 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
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

This response is AI-generated, for reference only.