RN Utilization Review Nurse – Care Coordination

Sentara Health; Wisconsin; On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical benefits

401k with employer match

Paid time off

Educational assistance

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management within licensure scope. Responsibilities include prior authorization, retrospective review, and care coordination for appropriate treatment.

The role requires RN licensure and a BSN is preferred. The candidate will review provider requests, issue decisions per criteria, and ensure compliance with accrediting standards and medical policies while maintaining clear communication with members

Qualifications

• BSN preferred as education requirement.
• RN license required.
• 3 years of acute care clinical experience.
• Experience with Utilization Review preferred.
• Knowledge of NCQA preferred.
• Microsoft Office (Word, Excel, Outlook) preferred.

Responsibilities

• Perform utilization management activities including prior authorization and retrospective review.
• Coordinate care and provide pre-certification and authorizations.
• Prepare and issue approval/denial letters per criteria.
• Ensure compliance with CMS/state regulations and medical policies.
• Communicate with members/providers and document decisions.

Skills

Communication skills

Interpersonal skills

Problem-solving

Analytical skills

Oral/written communication

Education

BSN (preferred)

3 years acute care clinical experience

Registered Nurse (RN)

NCQA knowledge (preferred)

Microsoft Office knowledge (preferred)

Tools

Microsoft Office Suite

Milliman

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management within licensure scope. Responsibilities include prior authorization, retrospective review, and care coordination for appropriate treatment.

The role requires RN licensure and a BSN is preferred. The candidate will review provider requests, issue decisions per criteria, and ensure compliance with accrediting standards and medical policies while maintaining clear communication with members