Utilization Review Nurse - RN, Care Coordination & Compliance

Sentara Health; Baton Rouge (LA); Sur place; USD 93 000 - 137 000; Plein temps

Avantages offerts par ce poste

Caring For Your Family and Your Career

Medical, Dental, Vision plans

Paid Time Off and Sick Leave

401k/403B with Employer Match

Tuition Assistance

Résumé du poste

Sentara Health Plans Community Care is seeking a Utilization Review Nurse (RN) to perform utilization management, including prior authorization and care coordination, across acute care settings. The role requires strong analytical and communication skills to ensure policy-compliant decisions and timeliness.

Qualifications include a BSN preferred and RN licensure, with at least 3 years of acute care experience and knowledge of Milliman and NCQA concepts.

Qualifications

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

Responsabilités

• Performs utilization management including prior authorization and pre-certification.
• Conducts retrospective reviews and medical director referrals.
• Executes member/provider approval or denial letters and coordinates care.
• Ensures compliance with CMS, state, medical policy and criteria for authorizations.

Connaissances

Communication skills

Analytical skills

Problem solving

Oral and written communication

Formation

BSN (preferred)

Outils

Milliman

Microsoft Word

Microsoft Excel

Microsoft Outlook

Description du poste

Sentara Health Plans Community Care is seeking a Utilization Review Nurse (RN) to perform utilization management, including prior authorization and care coordination, across acute care settings. The role requires strong analytical and communication skills to ensure policy-compliant decisions and timeliness.

Qualifications include a BSN preferred and RN licensure, with at least 3 years of acute care experience and knowledge of Milliman and NCQA concepts.