RN Utilization Review: Care Coordination & Compliance

Sentara Health; Lorida (FL); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Paid time off (vacation, sick, orholi-

Discretionary annual bonus if eligible

Adoption, fertility, surrogate reimb.

Emergency backup care

Long-term and short-term disability

Life insurance

Legal resources plan

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management activities within licensed scope. The role includes prior authorization, care coordination, and adherence to CMS/state criteria and medical policies. A Registered Nurse with at least 3 years of acute care experience is required.

The position offers a base salary of $93,184 to $136,947.20 annually, with potential for shift differentials and bonuses, and a comprehensive benefits package.

Qualifications

• RN required.
• 3 years of acute care clinical experience.

Responsibilities

• Performs utilization management services including prior authorization and retrospective reviews.
• Facilitates medical director referrals and prepares approval/denial letters.
• Performs pre-certification and care coordination to ensure treatment appropriateness.
• Verifies compliance with criteria, medical policy, and member contracts.
• Ensures medical director decisions align with criteria and accrediting standards.

Skills

Registered Nurse

Care coordination

Discharge planning

Case management

Milliman

NCQA

Microsoft Word

Microsoft Excel

Microsoft Outlook

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management activities within licensed scope. The role includes prior authorization, care coordination, and adherence to CMS/state criteria and medical policies. A Registered Nurse with at least 3 years of acute care experience is required.

The position offers a base salary of $93,184 to $136,947.20 annually, with potential for shift differentials and bonuses, and a comprehensive benefits package.