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

Entry Level Social Media Coordinator - Remote, No Experience Necessary

Sales & Customer Service Representative - Remote

Teach English or another language/subject Online, both natives and non natives accepted! $10-$3[...]

Entry-Level Online Chat Jobs - Remote Opportunities Earning $25-$35 Per Hour

Remote Customer Service Agent

Remote Data Entry Clerk / Typist – Flexible Paid Focus Group & Clinical Trial Participation (US & Canada)

No Experience Virtual Assistant - Flexible Schedule

Courier Driver: Local Deliveries & Customer Service

Work From Home Product Tester – $25-$45/hr – No Experience Needed

Remote Telehealth RN for Medicare Care & Education

Netflix Customer Service Advisor (Remote)

American Airlines Data Entry Clerk (Remote)

New Grad Registered Nurse (RN)

Data Entry Specialist - Work From Home

Business Analyst, Customer Contact Center

Data Entry Operator || Freshers & Experienced

Remote Full Desk Recruiter - Skilled Trades/Direct Hire - U.S. Remote

RN Appeals Analyst (Must Reside in SC)

Target Data Entry Jobs, Target Remote Jobs @ Joblagii ( Senior Account Executive )

Disney Remote (Data Entry, Advance Level Job) - Hiring Now

Bistro Attendant - Part Time

Remote School Social Worker - Maine

Remote Customer Support Representative – Travel & Booking Coordination

UPS Careers in Kerman, CA

[Hiring] Home-Based Insurance Services Representative @AIL

Retail Sales Associate / Guest Services - Hiring Teens (16 years old or above)

Venture Capital Associate at Toyota Research Institute: 100% Remote (San Francisco, CA, Los Altos, US)

Senior Manager - Digital Analytics at Walt Disney Company: Hybrid (Anaheim, CA)

Remote Jobs $30 An Hour, Disney Wfh Jobs ( Remote Ops Producer II )

Take Part in an Easy Product Photo Assignment Online

Watch Netflix (Tagger): $12-$46

Part-time Data Entry Assistant

Entry Level/No Experience Data Entry

Amazon Customer Service Representative (Remote)

Amazon Delivery Driver

[Hiring] Specialist, Amazon Operations @Belnick, LLC

Remote Amazon Customer Support Pro (Email & Chat)

Remote Group Benefits Sales Executive - Uncapped Commission

Service & Shipping Center Associate

Coca-Cola Data Entry Clerk (Remote)

Mobile app UX tester for contractor software - paid trial (iPhone or Android)

[Hiring] Advanced Care at Home RN @Hicuity Health

17 Ways to Make Money From Home -- Side Hustles and Gig Jobs Available

No Experience Needed Office Clerk

Utilization Management Nurse Consultant – Work at home – EST

[Hiring] Case Manager, RN @company

Amazon Delivery Driver

Revenue Recovery Specialist, Motor Vehicle Accident at Knowtion Health: 100% Remote (US)

Customer Experience Specialist - Pest Control

AI Generalist (No Experience Required)

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...