RN Utilization Review & Care Coordination

Sentara Health; South Dakota; Remote; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off

Tuition Assistance

Student Debt Pay Down

Parental Leave

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management activities across the care continuum. The role includes prior authorization, pre-certification, and care coordination to ensure treatment is appropriate and compliant with policy and regulatory standards.

The ideal candidate holds an RN license (BSN preferred) with acute care experience and familiarity with Milliman and NCQA guidelines.

Qualifications

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

Responsibilities

• Conducts utilization management services including prior authorization and retrospective review
• Performs pre-certification and care coordination for treatment appropriateness
• Notifies members and providers of determinations in writing or verbally
• Ensures decisions align with CMS/state medical policy and regulatory requirements

Skills

Utilization Review

Nurse

Microsoft Office

Communication

Problem Solving

Facilitation

Analytical Skills

Education

BSN (preferred)

Tools

Milliman

NCQA

Microsoft Office

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management activities across the care continuum. The role includes prior authorization, pre-certification, and care coordination to ensure treatment is appropriate and compliant with policy and regulatory standards.

The ideal candidate holds an RN license (BSN preferred) with acute care experience and familiarity with Milliman and NCQA guidelines.