Virginia Licensed Utilization Review Nurse

Job Summary

Working remotely on a full-time basis, the Virginia Licensed Utilization Review Nurse will manage prior authorization, inpatient review, and care coordination for imaging services, ensuring compliance with medical policies and member eligibility.

Key responsibilities:

• Conduct prior authorization and various reviews to assess the appropriateness of treatment settings
• Manage appeals for denied services and communicate decisions to members and providers
• Facilitate discharge planning and coordinate member care transitions with case management

Required qualifications:

• Registered Nurse (RN) License (Compact or Virginia) required
• Bachelor's Degree in Nursing preferred
• Three years of acute care clinical experience required
• Previous Utilization Review experience highly preferred
• Knowledge of NCQA standards preferred