Utilization Review Nurse/ RN for Imaging/Commercial- Remote!

Other Jobs To Apply

About the position

Sentara Health Plans is hiring a full-time, permanent Utilization Review Nurse for Imaging/Commercial. This remote role is available to candidates residing in the listed eligible states. The position is 40 hours per week, with standard hours of 8 a.m. to 5 p.m. Eastern Time, Monday through Friday. Weekend and holiday coverage is required; nurses self-schedule and are expected to work 13 weekend day shifts per year, in addition to assigned holiday coverage. The nurse performs utilization management services within the scope of licensure. The role reviews requests for services requiring authorization and supports prior authorization, inpatient and concurrent review, retrospective review, medical director referrals, and member/provider approval or denial notifications. Reviews assess appropriate treatment settings and compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts. The nurse may manage appeals, coordinates care transitions and discharge planning, and ensures medical director decisions are consistent with applicable criteria and regulatory requirements. Sentara Health Plans provides coverage to close to one million members in Virginia through commercial, Individual and Family, Medicare, and Medicaid plans, as well as Employee Assistance Programs. Its services include a broad provider network, chronic illness support, wellness programs, and integrated clinical and behavioral health services. Sentara describes its culture as family-friendly and supportive of community involvement, development, and growth. It is an equal opportunity employer and maintains a tobacco-free environment.

Responsibilities

  • Perform utilization management services within the scope of licensure.
  • Conduct prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and approval or denial letter processes for members and providers.
  • Review provider requests for services requiring authorization.
  • Conduct pre-certification, continued stay review, care coordination, and discharge planning or treatment-setting appropriateness reviews.
  • Ensure reviews comply with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Manage appeals for services that have been denied, as applicable.
  • Provide written and/or verbal notifications to members and providers.
  • Anticipate discharge planning needs, coordinate transitions of care jointly with case management, and facilitate member care transitions.
  • Ensure medical directors’ written decisions are consistent with CMS, state, medical policy, and clinical criteria.
  • Support accreditation by understanding, interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

  • Registered Nurse (RN) license, compact or Virginia, required.
  • Three years of acute care clinical experience required.

Nice-to-haves

  • Bachelor’s degree in Nursing preferred.
  • Previous utilization review experience highly preferred.
  • Previous imaging experience preferred.
  • InterQual or Milliman experience preferred.
  • Knowledge of NCQA preferred.

Benefits

  • Medical, dental, and vision plans.
  • Adoption, fertility, and surrogacy reimbursement up to \$10,000.
  • Paid time off and sick leave.
  • Paid parental and family caregiver leave.
  • Emergency backup care.
  • Long-term and short-term disability and critical illness plans.
  • Life insurance.
  • 401(k)/403(b) with employer match.
  • Tuition assistance up to \$5,250 per year and discounted educational opportunities through Guild Education.
  • Student debt pay down up to \$10,000.
  • Pet insurance.
  • Legal resources plan.
  • Opportunity to earn an annual discretionary bonus, subject to system and employee eligibility criteria.
  • Paid holidays.
  • Educational assistance or student loan repayment.
Back to blog

Other Jobs To Apply

Senior Product Manager – AI Innovation

OEM Customer Service Sales Support at Merit Medical: 100% Remote (US)

amazon flex $15+/ Hour (Sign on Bonus)!

Clinical Reviewer-RN (Remote U.S.)

Remote Travel Booking Agent (Flexible Schedule)

Call Center Specialist [Work From Home - Night Shift - Full Time]

Inside Sales Representative (Remote - Western Region)

Call Center Agent (Fully Remote)

Fitness Data Collector - Fully Remote

Coca Cola Careers in Goleta, CA

Part Time - Work from Home - Online Product Tester - No experience ($25-$45 per hour)

Administrative Assistant / Data Entry Clerk (Remote Work From Home Online)

UPS Remote Jobs (Data Entry| Full Time) Work From Home Jobs

Customer Care Representative- Work From Home in Kentucky

Data Entry Jobs For Beginners

Availability and Sustainability Specialist

Remote Entry-Level Customer Support – No Experience Required

Remote Data Entry Operator / Part-time

Walmart Data Entry Work From Home $30/H - Hiring Now

Remote Overnight Pharmacy Tech – PA Data Entry Expert

Lead UX Researcher - Supply Chain

"No Experience? No Problem! 100% Remote Entry Level Job - Starting this week

SCA Call Center Registered Nurse - Remote

Target Remote Jobs Near Me $30/Hour Job ID- 1047 Job ID- 3290

Driver

Nevada Radiology option-Remote Evening work

Remote Senior Copywriter Healthcare Brand & Growth

American Airlines Remote, Airline Remote Jobs, Remote American Airlines Jobs Get Job From Here![...]

UPS - Warehouse Worker/Package Handler $16-$35/hr

Auto Physical Damage Appraiser - Field

Netflix Work From Home Job Remote @ Get Dream Job

Data Entry Specialist, Part-Time

Remote Customer Service Specialist

Amazon Delivery Driver

Senior Dam Safety Engineer - Remote

Online Jobs for 16 Year Old No Experience

Remote Flight Reservationist

Remote Chat Operator — Chat Support & Moderator

Remote Work From Home Data Entry Clerk / Typing

Remote Part-Time Clinical Data Abstractor - Flexible Hours

Fully Remote Setup Entry-Level Opportunity No Experience Required

Call Center Specialist [Work From Home - Night Shift - Full Time]

Test Products from Home – $25-$45/hr + Freebies

[Hiring] Manager, Learning Systems & Enablement @RTX

-Entry-Level Remote Careers | No Experience Needed | Immediate Start

Part Time Data Entry Clerk (Remote)

Utilization Management Nurse Consultant – Preference for Virginia Residents

Member Service Representative, Roadside Assistance (Work from Home)

Fleet Service Agent -FAT

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...