Medical Policy Research Specialist/ Registered Nurse (RN) - Remote in Virginia

Sentara Health Plan is currently hiring a Medical Policy Research Specialist/ Registered Nurse (RN) - Remote in Virginia!

Status: Full-time, permanent position (40 hours)

Work hours: 8am to 5pm EST, M-F

Location: This position is remote in Virginia, with a travel expectation of 1x a month to Sentara Park 1330 in Virginia Beach, VA for candidates residing in the Hampton Roads area.

Job Responsibilities:

• Medical Policy Research Specialist is responsible for ongoing identification and research of medically evidence-based clinical technologies that form the basis for clinical decision-making, medical policy and benefit development and determination.
• Will maintain the database of clinical criteria, ensure technology and policy reviews are reviewed on an annual and ongoing basis to meet Federal, State and Accreditation Standards.
• Will be proficient with the Healthcare Industry's changing National Guidelines, new medical treatments, and devices, and will compile information for the Plan related to clinical indications and use of the technology, alternative technologies that address these same indications, and clinical outcomes expected given the use of the technology.
• Will perform a comprehensive clinical literature review, obtain legal and regulatory status of the technology, review Federal, State, and local coverage determinations, and identify current coverage policies and procedures.
• Collaborates with Medical Directors and teams on clinical guideline/medical policy/regulatory guidance updates.

Education:

• BLD - Bachelor's Level Degree in Nursing REQUIRED

Certificate/Licenses:

• Active RN in VA or Compact/Multistate REQUIRED

Experience:

• Related experience in clinical criteria coverage- 3 years REQUIRED
• Managed Care - 3 years REQUIRED
• Knowledge of medical policy, emerging technology, and analysis of emerging evidence REQUIRED
• Familiarity with primary clinical literature, clinical guidelines and/or medical policies.
• Working knowledge of PubMed and literature search methodology.
• Experience with Imaging/Radiology preferred
• Experience with policy writing process preferred
• The ability to assimilate and work through data sets preferred

Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees.

Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.

We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health servicesall to help our members improve their health.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission "to improve health every day," this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.