Utilization Review Nurse - RN, Care Coordination

Sentara Health; Maryland City (MD); Sur place; USD 93 000 - 137 000; Plein temps

Avantages offerts par ce poste

Medical, Dental, Vision plans

Paid Time Off and Sick Leave

Educational assistance or student loan

Résumé du poste

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management functions within the licensed scope. You will perform prior authorization, retrospective review, and care coordination to ensure appropriate care and adherence to policy and contracts.

Required RN license with BSN preferred and at least 3 years of acute care experience. Milliman and NCQA knowledge, plus strong communication and analytical skills, are highly valued.

Qualifications

• 3 years of acute care clinical experience (required).
• Prior Utilization Review experience (preferred).
• Milliman experience (preferred).
• Knowledge of NCQA (preferred).
• Strong oral, written and interpersonal communication skills.

Responsabilités

• Provides utilization management services within licensed scope.
• Performs prior authorization, retrospective review, and care coordination.
• Reviews requests for services requiring authorization and notifies providers and members.
• Ensures decisions align with CMS, state, and clinical criteria.

Connaissances

Communication skills

Analytical skills

Problem-solving

Facilitation

Interpersonal skills

Formation

BSN (preferred)

Outils

Microsoft Office

Description du poste

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to manage utilization management functions within the licensed scope. You will perform prior authorization, retrospective review, and care coordination to ensure appropriate care and adherence to policy and contracts.

Required RN license with BSN preferred and at least 3 years of acute care experience. Milliman and NCQA knowledge, plus strong communication and analytical skills, are highly valued.