Virginia Licensed Utilization Review Nurse

Job Summary

Managing utilization management services, the full-time Virginia Licensed Utilization Review Nurse will conduct prior authorizations, inpatient reviews, and care coordination remotely while ensuring compliance with medical policies and member eligibility.

Key responsibilities

• Conduct prior authorization, inpatient, concurrent, and retrospective reviews for services requiring authorization
• Facilitate member care transitions and discharge planning in collaboration with case management
• Ensure compliance with accrediting and regulatory requirements while managing appeals for denied services

Required qualifications

• Registered Nurse (RN) License (Compact or Virginia) is required
• Bachelor's Degree in Nursing is preferred
• Minimum of 3 years of acute care clinical experience is required
• Previous experience in Utilization Review is highly preferred
• Experience with LTSS Waiver or Medicaid is highly preferred