Virginia Licensed Utilization Review Nurse

Job Summary

To support Medicaid services, the full-time Virginia Licensed Utilization Review Nurse will conduct prior authorizations, inpatient reviews, and care coordination remotely, ensuring compliance with medical policies and member eligibility while participating in weekend and holiday coverage.

Key responsibilities

• Conduct prior authorization, inpatient, concurrent, and retrospective reviews for Medicaid services
• Manage appeals for denied services and provide written/verbal notifications to members and providers
• Facilitate discharge planning and care transitions in collaboration with case management

Required qualifications

• Registered Nurse (RN) License (Compact or Virginia) is required
• Bachelor's Degree in Nursing is preferred
• At least 3 years of acute care clinical experience is required
• Previous experience in Utilization Review is highly preferred
• Familiarity with InterQual or Milliman criteria is preferred