UTILIZATION REVIEW NURSE

City/State

Norfolk, VA

Work Shift

First (Days)

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. 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.

Education:

· BSN (preferred)

Certification:

· Registered Nurse (required)

Experience:

· 3 years of acute care clinical experience (required)

· Previous Utilization Review experience (preferred)

· Milliman experience (preferred)

· Knowledge of NCQA (preferred)

· Microsoft suite (Word, Excel, Outlook) (preferred)

· Requires strong oral, written and interpersonal communication skills,
problem-solving skills, facilitation skills, and analytical skills

Keywords: Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or
Discharge Planning, Case Management, Milliman, NCQA

We provide market-competitive compensation packages, inclusive of base pay,
incentives, and benefits. The base pay range for full-time employment is
$93,184.00 - $136,947.20 annually. Additional compensation may be available for
this role, such as shift differentials, standby/on-call pay, overtime, shift
premiums, extra-shift incentives, or bonus opportunities. Compensation within
the range may vary based on qualifications, experience, location, market
conditions, and business needs. Note: If an annual salary is posted, it is based
on a full-time colleague working 2,080 hours annually.

Benefits: Caring For Your Family and Your Career

• 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.

Sentara Health is an equal opportunity employer and prides itself on the
diversity and inclusiveness of its close to an almost 30,000-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.