Role Description Sentara Health Plans is hiring a Utilization Review Nurse/ RN for Medicaid - Remote! • Status: Full-time, permanent position (40 hours) • Standard working hours: 8am to 5pm EST, M-F • Weekend and holiday coverage required • Nurses participate in a self-scheduling process and are expected to work 13 weekend day shifts per year, as well as assigned holiday coverage Job responsibilities: • 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 • Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews • Ensures 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 Qualifications • Bachelors Degree in Nursing (preferred) • Registered Nurse (RN) License (Compact or Virginia) - REQUIRED • 3 years of acute care clinical experience - REQUIRED • Previous Utilization Review - highly preferred • Previous LTSS Waiver OR Medicaid experience - highly preferred • InterQual or Milliman experience - preferred • Knowledge of NCQA - preferred • Strong oral, written and interpersonal communication skills • Problem-solving skills, facilitation skills, and analytical skills • Strong Microsoft skills (Word, Excel, Outlook and Teams) 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 Apply To this Job Company : Sentara Health Salary : Work from home