RN Utilization Review & Care Coordination

Sentara Health; Philadelphia (Philadelphia County); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid Time Off

Job summary

Sentara Health Plans Community Care seeks a dedicated Utilization Review Nurse in Norfolk, VA. You will manage prior authorization, retrospective review, pre-certification, and care coordination to ensure appropriate treatment and adherence to medical policy and contracts.

Requires RN license with BSN preferred; 3 years acute care experience and familiarity with Milliman, NCQA, and MS Office are advantageous. Competitive compensation and benefits offered.

Qualifications

• BSN (preferred).
• 3 years of acute care clinical experience (required).
• Prior Utilization Review experience (preferred).
• Milliman experience (preferred).
• Knowledge of NCQA (preferred).
• Microsoft Office (Word, Excel, Outlook) (preferred).
• Strong oral, written and interpersonal communication, problem-solving, facilitation and analytical skills.

Responsibilities

• Perform utilization management services including prior authorization, retrospective review, and pre-certification.
• Coordinate care and review services for appropriateness of treatment, ensuring compliance with criteria and policy.
• Provide written or verbal notification to members and providers and align decisions with medical policy and contracts.

Skills

Acute care experience

Utilization review

Communication skills

Problem solving

Interpersonal skills

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care seeks a dedicated Utilization Review Nurse in Norfolk, VA. You will manage prior authorization, retrospective review, pre-certification, and care coordination to ensure appropriate treatment and adherence to medical policy and contracts.

Requires RN license with BSN preferred; 3 years acute care experience and familiarity with Milliman, NCQA, and MS Office are advantageous. Competitive compensation and benefits offered.