Utilization Review RN | Care Coordination & Authorization

Sentara Health; Nashville (TN); 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

Parental & Family Caregiver Leave

Education assistance

Student Debt Pay Down

Tuition Assistance

Life Insurance

Disability plans

Bonuses possible

Tuition Assistance - $5,250/year

Job summary

Sentara Health Plans Community Care in Norfolk, VA is hiring a Utilization Review Nurse. The role involves utilization management, prior authorization, retrospective review, and care coordination to ensure appropriate treatment and adherence to medical policies.

You will work with providers and members, issue written decisions, and support accreditation and regulatory standards. RN license required; BSN preferred; 3 years acute care experience; Milliman/NCQA knowledge valued; comprehensive

Qualifications

• Active RN license in good standing.
• BSN preferred.
• 3 years of acute care clinical experience required.
• Experience with utilization review; Milliman/ NCQA knowledge preferred.

Responsibilities

• Perform utilization management activities including prior authorization and pre-certification.
• Coordinate care and clinical approvals/denials per policy.
• Provide written and verbal communications to members and providers.
• Ensure compliance with CMS, state and medical policy criteria.

Skills

RN License

Prior authorization

Care coordination

Analytical skills

Communication skills

Education

BSN (preferred)

Nursing Degree

Tools

Microsoft Word

Excel

Outlook

Job description

Sentara Health Plans Community Care in Norfolk, VA is hiring a Utilization Review Nurse. The role involves utilization management, prior authorization, retrospective review, and care coordination to ensure appropriate treatment and adherence to medical policies.

You will work with providers and members, issue written decisions, and support accreditation and regulatory standards. RN license required; BSN preferred; 3 years acute care experience; Milliman/NCQA knowledge valued; comprehensive