Utilization Review Nurse: Prior Authorization & Care Coordination

Sentara Health; Texas; 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 / student loan

Tuition Assistance

Job summary

Sentara Health Plans Community Care is seeking a dedicated Utilization Review Nurse responsible for utilization management within the scope of licensure. Conducts prior authorization, retrospective review, medical director referrals and execution of member/provider approval/denial letters.

Reviews provider requests for services requiring authorization and coordinates care for treatment appropriateness. The role requires an RN with BSN preferred and 3 years of acute care experience; familiarity

Qualifications

• 3 years of acute care clinical experience (required).
• Previous Utilization Review experience (preferred).
• Knowledge of NCQA (preferred).
• Strong oral, written and interpersonal communication skills, problem-solving, facilitation, and analytical skills.
• Milliman experience (preferred).
• Microsoft Office suite (Word, Excel, Outlook) (preferred).

Responsibilities

• Performs prior authorization, retrospective review, and medical director referrals.
• Executes member/provider approval or denial letters and pre-certifications.
• Coordinates care for appropriateness of treatment and ensures compliance with criteria and policies.
• Communicates outcomes to members and providers; supports accreditation requirements.

Skills

Communication skills

Problem solving

Facilitation

Analytical skills

Education

BSN (preferred)

Registered Nurse (required)

Tools

Milliman

Microsoft Office (Word, Excel, Outlook)

Job description

Sentara Health Plans Community Care is seeking a dedicated Utilization Review Nurse responsible for utilization management within the scope of licensure. Conducts prior authorization, retrospective review, medical director referrals and execution of member/provider approval/denial letters.

Reviews provider requests for services requiring authorization and coordinates care for treatment appropriateness. The role requires an RN with BSN preferred and 3 years of acute care experience; familiarity