Virginia Premier Health Plan, Inc.

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RN Clinical Reviewer

RN Clinical Reviewer

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


This position is responsible for reviewing and authorizing waiver services under CCC Plus according to the approved criteria across the continuum of care to ensure positive member outcomes while controlling costs by performing timely clinical reviews, identifying over/under utilization, and collaborating with the care coordination team to ensure appropriate waiver services are in place for members.


  • Obtains, reviews, and enters clinical information from service providers for the following services: EDCD (agency directed and consumer directed), Tech waiver, respite, Private Duty Nursing, Assistive Technology and/or Maintenance, Environmental Modification and/or Maintenance, Transitions, Nursing Facility, Adult Day Health Care, Services Facilitation, PERS, Hospice, Congregate Nursing, and other LTSS services included under CCC Plus.
  • Utilizes DMAS guidance (such as the EDCD or Nursing Facility manuals) to perform clinical reviews for waiver services
  • Demonstrates comprehensive understanding of criteria for members receiving various waiver services
  • Adheres to expected turnaround times for LTSS requests (5 days standard; 3 days expedited)
  • Refers requests to the Medical Directors to determine medical necessity and appropriateness of care
  • Generates and sends approval letters to members and providers according to VPHP policies and procedures
  • Collaborates with the assigned care coordinator to ensure waiver services are appropriate for the member
  • Participates in interdisciplinary care team meetings
  • Participates in hospital rounds with the care coordination team
  • Participates in VPHP’s ongoing quality improvement process
  • Participates in continuing educational activities as appropriate
  • Other duties as assigned
  • This position provides services and demonstrates the knowledge and ability to meet the specific needs of the following age groups:   All       Infant       Adult       Child       Geriatric



  • Current Virginia RN Licensure
  • BSN preferred


  • Knowledge of Medicaid waiver services (such as EDCD, Tech, Nursing Facility, Adult Day Health, Private Duty Nursing)
  • Demonstrates ability to negotiate with service providers
  • Demonstrates proficiency in work with various application of Microsoft Office (specifically Excel)
  • Knowledge of community resource options and experience in making appropriate referrals
  • Possess a working knowledge of ICD-10 and CPT-4 coding


  • Minimum of three years clinical experience and/or current managed care experience



Physical health sufficient to meet the ergonomic standards and demands of the position.




About Us


Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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