RN Utilization Review Specialist: Care Coordination

Sentara Health; South Dakota Park (SD); In loco; USD 93.000 - 137.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off and Holidays

Tuition Assistance

Descrizione del lavoro

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management services within licensure. Responsibilities include prior authorization, retrospective reviews, and care coordination to assure appropriate treatment and compliance with policy and contracts.

The role requires an RN, BSN preferred, and about 3 years of acute care experience, with Milliman and NCQA knowledge considered a plus.

Competenze

• RN license required
• 3 years of acute care clinical experience (required)
• Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft Office proficiency (Word, Excel, Outlook) (preferred)
• Strong written and verbal communication, problem-solving and analytical skills

Mansioni

• Perform utilization management services including prior authorization and retrospective reviews
• Coordinate pre-certification and care coordination for appropriate treatment
• Ensure decisions align with medical policy, criteria and member contracts
• Provide notification to members and providers and support regulator/compliance requirements

Conoscenze

Communication skills

Problem-solving

Facilitation skills

Analytical skills

Oral & written communication

Formazione

BSN (preferred)

Strumenti

Microsoft Word

Microsoft Excel

Microsoft Outlook

Milliman

NCQA

Descrizione del lavoro

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management services within licensure. Responsibilities include prior authorization, retrospective reviews, and care coordination to assure appropriate treatment and compliance with policy and contracts.

The role requires an RN, BSN preferred, and about 3 years of acute care experience, with Milliman and NCQA knowledge considered a plus.