RN Utilization Review | Authorization & Care Coordination

Sentara Health; Guin (AL); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Adoption, Fertility and Surrogacy Reim

Emergency Backup Care

Long-Term Disability

Short-Term Disability

Life Insurance

Legal Resources Plan

Annual discretionary bonus eligibility

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management within licensure, including prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letters.

This role also handles pre-certification and care coordination to ensure treatment is appropriate and compliant with criteria, policies, and contracts.

Qualifications

• RN with at least 3 years of acute care clinical experience.
• Experience with utilization management processes and referrals.
• Proficiency with Microsoft Word, Excel and Outlook preferred.

Responsibilities

• Perform utilization management services within licensure, including prior authorization and retrospective review.
• Coordinate precertification, care coordination, and eligibility checks with medical policy and contracts.
• Ensure medical director decisions align with CMS/state criteria and support accreditation activities.

Skills

Prior Authorization

Care Coordination

Utilization Review

Medical policy interpretation

Education

Registered Nurse (RN)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management within licensure, including prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letters.

This role also handles pre-certification and care coordination to ensure treatment is appropriate and compliant with criteria, policies, and contracts.