Denial Resource Center RN

Quality Review Nurse

Who are we?

Versant Health is one of the nation’s leading administrators of managed vision care, serving over 35 million of our clients’ members across the United States. Our purpose is to make healthy vision a reality for everyone by improving access to care and education in the communities we serve. Fueled by our mission to improve members’ lives with easy-to-use vision solutions rooted in choice value, and care, we believe that everyone has the power to become anything they set their sights on.

See how you can make a difference with the support of strong leadership and a team environment.

Versant Health: Making Healthy Vision a Reality for Everyone

What are we looking for?

The Quality Review Nurse works within the Utilization Management team to bring additional clinical expertise to the prior authorization and denial review processes. The Quality Review Nurse applies specific criteria and payer guidelines to ensure that all healthcare services provided are optimized for quality and timeliness of the care. This role serves as the clinical support person for the Utilization Management Team and as a subject matter expert (SME) for member friendly language and denial letter review.

Where you will have an impact

• Serve as a clinical resource to the Utilization Management Team
• Serve as a SME for member friendly language notification letters
• Provide quality clinical review and edits of all denial letters to ensure NCQA requirements are met
• Maintain a quality tracking log of all letters reviewed
• Quality Clinical Review of authorization requests
• Apply specific medical criteria and payer guidelines when reviewing clinical documentation for medical necessity
• Ensure services provided to eligible members are within the benefit plan and that appropriate contracted providers are being utilized
• Identify and refer cases for second level review when necessary
• Follow and apply all regulatory requirements for assigned markets
• Monitor reporting to track missing diagnosis codes and update prior authorization to reflect properly assigned diagnosis codes on a weekly basis
• Work closely with utilization management leadership to ensure the continual compliance of all QA/QI initiatives
• Contribute to a positive work culture by modeling excellence in both work ethic and team interactions
• Perform additional duties as assigned
  
  

What’s necessary to do the job?

• Graduate of an accredited Practical Nursing program required.
• 3+ years of related experience in utilization management required
• 3+ years of clinical experience in acute care required
• Proficiency in Microsoft Office suite required
• Active, unrestricted LNP or LVN license in state of residence, or compact state licensure required.
• Knowledge and experience in the insurance, health, or vision care industry perferred
  
  

HIPAA & Security Requirements

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

We offer a comprehensive and competitive total rewards package designed to support your health, financial well‑being, and work‑life balance. Benefits include medical, dental, and paid vision coverage; paid time off and company holidays; retirement savings with employer contribution; employee wellness resources; and professional development opportunities. Additional benefits may include flexible work arrangements, employee assistance programs, and other programs that support you both at work and beyond.

Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.

Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

Our purpose is to make healthy vision a reality for everyone by improving access to care and education in the communities we serve. Fueled by our mission to improve members’ lives with easy-to-use vision solutions rooted in choice, value, and care, Versant Health believes that everyone has the power to become anything they set their sights on.

Our team is guided by core Leadership Principles—Perspective, Care, Drive, and Ownership—which shape how we work, lead, and grow together.

Our Management Team is committed to fostering a strong and supportive culture, cultivating a thriving work environment, providing clear direction, optimizing resources, enabling innovative solutions, and driving meaningful results.