RN Utilization Review & Prior Authorization Specialist

Sentara Health; Salem (NH); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Adoption, Fertility and Surrogacy Reim

Emergency Backup Care

Long-Term Disability

Short-Term Disability

Critical Illness plans

Life Insurance

Legal Resources Plan

Annual discretionary bonus potential

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management within licensure. You will perform prior authorizations, retrospective reviews, medical director referrals, and issue approval/denial letters as required.

The role also involves pre-certification, care coordination for treatment appropriateness, and applying CMS/state criteria to ensure compliance and eligibility.

Qualifications

• Must hold an active Registered Nurse license (RN).
• Minimum 3 years of acute care clinical experience required.
• Proficiency with Microsoft Word, Excel and Outlook is preferred.

Responsibilities

• Performs prior authorization and retrospective review as part of utilization management.
• Handles medical director referrals and issues of approval/denial letters to members/providers.
• Conducts pre-certification, care coordination for treatment appropriateness, and set reviews.
• Applies CMS, state, medical policy, and clinical criteria to determine eligibility.
• Ensures decisions align with accrediting/regulatory standards.

Skills

Word

Excel

Outlook

Care Coordination

Education

Registered Nurse (RN) license

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management within licensure. You will perform prior authorizations, retrospective reviews, medical director referrals, and issue approval/denial letters as required.

The role also involves pre-certification, care coordination for treatment appropriateness, and applying CMS/state criteria to ensure compliance and eligibility.