Commercial Utilization Review Nurse/RN- Remote in VA

Sentara Health, an integrated, not-for-profit health care delivery system, celebrates more than 135 years in pursuit of its mission - "we improve health every day." Sentara is one of the largest health systems in the U.S. Mid-Atlantic and Southeast, and among the top 20 largest not-for-profit integrated health systems in the country, with 34,000 employees, 12 hospitals in Virginia and Northeastern North Carolina, including 10 hospitals with the prestigious Magnet®️ recognition, and the Sentara Health Plans division which serves more than 1 million members in Virginia and Florida. Sentara is recognized nationally for clinical quality and safety and is strategically focused on innovation and creating an extraordinary health care experience for our patients and members. Sentara was named a Health Quality Innovator of the Year (2024), was recognized by Forbes as "America’s Best-In-State Employer” (2024), "Best Employer for Veterans" (2022, 2023), and "Best Employer for Women" (2020), and named to IBM Watson Health's "Top 15 Health Systems" (2021, 2018).

Sentara Health is currently hiring for a Utilization Review Nurse- Remote in VA! Status: Full-time, permanent position (40 hours) Standard working hours: 8am to 5pm EST, M-F. Location: Remote in Virginia.

RN Clinician responsible for utilization 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 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 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.