Utilization Review Nurse
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Job Location:
Norfolk, MA - USA
Monthly Salary:
Not Disclosed
Posted on:
Yesterday
Vacancies:
1 Vacancy
Job Summary
City/State
Norfolk VAWork Shift
First (Days)Overview:
Sentara Health is looking to hire a Remote Utilization Review Nurse.
This is a remote position: Remote opportunities 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 (state) West Virginia Wisconsin Wyoming
Must be flexible to work on rotating weekends including holidays.
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 directors 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:
- Associates required.
- Bachelors preferred.
Certification:
- Registered Nurse required.
Experience:
- 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: $66830.4 $111384. Additional compensation may be available for this role such as shift differentials standby/on-call overtime premiums extra shift incentives or bonus opportunities
Keywords: Utilization Review Acute Care RN NCQA Milliman JIVA
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus ifestablished system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30000-member 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.
Required Experience:
IC
Key Skills
- EMR Systems
- Hospital Experience
- Acute Care
- ICU Experience
- Dermal Fillers
- Experience Administering Injections
- Home Care
- Nursing
- Botox Experience
- Critical Care Experience
- Medication Administration
- Tube Feeding
About Company
Sentara Health, is an integrated, not-for-profit health care delivery system in Virginia and North Carolina. Sentara improves health everyday.
