RN Utilization Review Specialist – Care Coordination

Sentara Health; Atlanta (GA); 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 or student loan

Paid Parental & Family Caregiver Leave

Life Insurance & Disability plans

Bonus opportunities

Job summary

Sentara Health Plans Community Care is seeking a qualified Utilization Review Nurse (RN) to manage prior authorization, retrospective reviews, and care coordination in accordance with CMS and medical policy.

The role requires an active RN license, BSN preferred, and at least 3 years of acute care experience. Milliman and NCQA familiarity, plus strong written and verbal communication, are highly valued as you support member and provider decisions.

Qualifications

• BSN preferred.
• RN license required.
• 3 years acute care clinical experience required.
• Utilization Review and Milliman experience preferred.
• Knowledge of NCQA preferred.
• Proficient in Microsoft Word, Excel, Outlook.

Responsibilities

• Perform utilization management activities including prior authorization and retrospective review.
• Coordinate care and document approvals/denials per policy.
• Communicate decisions to members and providers.
• Ensure compliance with CMS, state, and medical policy criteria.

Skills

Communication skills

Analytical thinking

Problem-solving

Interpersonal skills

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Outlook

Job description

Sentara Health Plans Community Care is seeking a qualified Utilization Review Nurse (RN) to manage prior authorization, retrospective reviews, and care coordination in accordance with CMS and medical policy.

The role requires an active RN license, BSN preferred, and at least 3 years of acute care experience. Milliman and NCQA familiarity, plus strong written and verbal communication, are highly valued as you support member and provider decisions.