RN Utilization Review: Care Coordination & Approvals

Sentara Health; Columbia (SC); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical plans

Dental plans

Vision plans

Adoption reimbursement

Fertility reimbursement

Surrogacy reimbursement

Paid Time Off

Parental leave

Family care leave

Emergency backup care

Disability insurance

Life Insurance

401k match

Tuition assistance

Student debt pay down

Pet Insurance

Legal resources plan

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to provide utilization management services under licensure. Duties include prior authorization, retrospective review, care coordination, and execution of member/provider approvals or denials with adherence to CMS and state criteria.

The role requires RN licensure, BSN preferred, and at least 3 years of acute care experience, with preferred familiarity in Milliman, NCQA, and Microsoft Office tools.

Qualifications

• RN license required.
• BSN preferred.
• 3 years of acute care clinical experience required.
• Experience with Utilization Review preferred.
• Familiarity with Milliman, NCQA, and CMS criteria preferred.

Responsibilities

• Perform utilization management services including prior authorization and pre-certification.
• Review requests for services requiring authorization and coordinate care for appropriateness of treatment.
• Notify members and providers of decisions in writing or verbally.
• Ensure decisions align with CMS, state, medical policy and criteria; support accreditation efforts.

Skills

Oral & Written Communication

Interpersonal skills

Analytical skills

Problem solving

Facilitation

Education

BSN

Tools

Microsoft Office

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to provide utilization management services under licensure. Duties include prior authorization, retrospective review, care coordination, and execution of member/provider approvals or denials with adherence to CMS and state criteria.

The role requires RN licensure, BSN preferred, and at least 3 years of acute care experience, with preferred familiarity in Milliman, NCQA, and Microsoft Office tools.