RN Utilization Review: Prior Auth & Care Coordination

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

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off and Holidays

Educational assistance

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to deliver utilization management services with licensure scope. You will handle prior authorizations, pre-certifications, and care coordination to ensure appropriate treatment and policy alignment.

The role requires an RN with at least 3 years of acute care experience. Preference given to candidates with Milliman, NCQA knowledge, and strong communication and analytical skills.

Qualifications

• Requires BSN preferred; RN license required.
• Three years of acute care clinical experience is required.
• Experience with utilization review and familiarity with Milliman, NCQA, and related regulatory standards is preferred.

Responsibilities

• Perform utilization management functions including prior authorization, retrospective review, and care coordination.
• Provide written or verbal notifications to members and providers.
• Ensure decisions comply with CMS, state, and medical policy criteria and regulatory standards.

Skills

Strong communication skills

Analytical skills

Interpersonal communication

Problem-solving skills

Facilitation skills

Education

BSN (preferred)

RN (required)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to deliver utilization management services with licensure scope. You will handle prior authorizations, pre-certifications, and care coordination to ensure appropriate treatment and policy alignment.

The role requires an RN with at least 3 years of acute care experience. Preference given to candidates with Milliman, NCQA knowledge, and strong communication and analytical skills.