RN Utilization Review: Care Coordination Champion

Sentara Health; Baltimore (MD); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Tuition Assistance

Paid Time Off

Job summary

Sentara Health Plans Community Care seeks an experienced Utilization Review Nurse. You will perform utilization management, prior authorizations, and care coordination to ensure appropriate treatment per policy and requirements. You will communicate decisions to members and providers and support regulatory accreditation processes.

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

Qualifications

• BSN preferred; RN required.
• 3 years of acute care clinical experience.
• Previous Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.

Responsibilities

• Perform utilization management including prior authorization and retrospective reviews.
• Coordinate care and provide written/verbal notification to members and providers.
• Ensure decisions align with CMS, state requirements and medical policy.
• Apply accrediting and regulatory standards in daily practice.

Skills

Communication skills

Analytical skills

Facilitation

Problem-solving

Interpersonal skills

Education

BSN (preferred)

Registered Nurse (required)

Tools

Microsoft Word

Excel

Outlook

Job description

Sentara Health Plans Community Care seeks an experienced Utilization Review Nurse. You will perform utilization management, prior authorizations, and care coordination to ensure appropriate treatment per policy and requirements. You will communicate decisions to members and providers and support regulatory accreditation processes.

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