Utilization Review Nurse — Care Coordination & Compliance

Sentara Health; Montgomery (AL); 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

Tuition Assistance

Job summary

Sentara Health Plans Community Care is hiring a Utilization Review Nurse to manage utilization management services, including prior authorization and care coordination. The nurse ensures responses align with medical policy, CMS guidelines, and contracts, with strong communication to members and providers.

The role requires RN licensure, a BSN preferred, and at least 3 years of acute care experience; Milliman or NCQA familiarity is a plus, along with proficiency in Microsoft Office.

Qualifications

• BSN preferred.
• RN licensure required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office proficiency preferred.

Responsibilities

• Perform utilization management including prior authorization, retrospective review, and medical director referrals.
• Carry out pre-certification and care coordination for treatment appropriateness.
• Review provider requests for services requiring authorization.
• Ensure decisions align with CMS, state, policy, and contracts.
• Provide member/provider notification and support accrediting standards.

Skills

Acute care experience

Communication skills

Problem solving

Facilitation

Analytical skills

Education

BSN (preferred)

Tools

Milliman

Microsoft Office

NCQA knowledge

Job description

Sentara Health Plans Community Care is hiring a Utilization Review Nurse to manage utilization management services, including prior authorization and care coordination. The nurse ensures responses align with medical policy, CMS guidelines, and contracts, with strong communication to members and providers.

The role requires RN licensure, a BSN preferred, and at least 3 years of acute care experience; Milliman or NCQA familiarity is a plus, along with proficiency in Microsoft Office.