RN Utilization Review Specialist | Care Coordination & Compliance

Sentara Health; United States; Presencial; USD 93.000 - 137.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, Dental, Vision plans

Paid Time Off and Holidays

401k/403(b) with employer match

Tuition Assistance

Descripción de la vacante

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management under RN licensure, handling prior authorizations, retrospective reviews, and care coordination to ensure appropriate treatment.

This full-time role requires a BSN (preferred) and 3 years of acute care experience, with NCQA and Milliman familiarity considered assets. Competitive benefits and professional growth opportunities are offered.

Formación

• RN required; strong oral and written communication skills.
• BSN preferred as education credential.
• 3 years of acute care clinical experience required.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office Suite experience preferred.

Responsabilidades

• Provide utilization management services under licensure.
• Perform prior authorization, retrospective review, and medical director referrals.
• Review provider requests for services requiring authorization; issue approvals/denials.
• Coordinate care for appropriateness of treatment and eligibility criteria.
• Ensure decisions align with CMS, state requirements, and medical policy.
• Notify members and providers in writing or verbally; support accreditation efforts.

Conocimientos

Oral communication

Written communication

Interpersonal skills

Problem-solving

Facilitation skills

Analytical skills

MS Office proficiency

Educación

RN (required)

BSN (preferred)

Herramientas

Microsoft Word

Microsoft Excel

Microsoft Outlook

Descripción del empleo

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to perform utilization management under RN licensure, handling prior authorizations, retrospective reviews, and care coordination to ensure appropriate treatment.

This full-time role requires a BSN (preferred) and 3 years of acute care experience, with NCQA and Milliman familiarity considered assets. Competitive benefits and professional growth opportunities are offered.