RN Utilization Review Specialist – Care Coordination

Sentara Health; Austin (TX); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) match

Paid time off

Parental leave

Family care leave

Tuition assistance

Job summary

Sentara Health Plans Community Care in Norfolk, VA is hiring a Utilization Review Nurse to manage utilization management services under licensure. The role includes prior authorization, retrospective reviews, care coordination, and ensuring compliance with CMS and medical policy while communicating decisions to members and providers.

Requirements include RN licensure, BSN preferred, and at least 3 years of acute care experience; familiarity with Milliman, NCQA, and Microsoft Office is preferred.

Qualifications

• BSN preferred.
• RN licensure required.
• 3 years of acute care experience required.
• Utilization review and/or Milliman experience preferred.

Responsibilities

• Perform prior authorization and retrospective reviews.
• Coordinate care and ensure appropriate treatment.
• Notify members/providers of decisions in writing/verbal form.
• Adhere to CMS/state regulations and medical policy.

Skills

Utilization review

Strong communication

Analytical skills

Problem solving

Teamwork

Education

BSN (preferred)

Tools

Milliman

NCQA

Microsoft Office

Job description

Sentara Health Plans Community Care in Norfolk, VA is hiring a Utilization Review Nurse to manage utilization management services under licensure. The role includes prior authorization, retrospective reviews, care coordination, and ensuring compliance with CMS and medical policy while communicating decisions to members and providers.

Requirements include RN licensure, BSN preferred, and at least 3 years of acute care experience; familiarity with Milliman, NCQA, and Microsoft Office is preferred.