Utilization Review RN: Care Coordination & Compliance

Sentara Health; Bismarck (ND); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical plan

Dental plan

Vision plan

Life Insurance

Disability insurance

401k/403B with Employer Match

Paid Time Off

Sick Leave

Holidays

Paid Parental Leave

Education assistance

Student Debt Pay Down

Adoption Reimbursement

Job summary

Sentara Health Plans Community Care in Norfolk, VA is seeking a licensed RN for our Utilization Review team. This role performs prior authorization, retrospective review, medical director referrals, and care coordination to ensure appropriate treatment and policy compliance.

Requirements include RN licensure, BSN preferred, and at least 3 years of acute care experience. Milliman/NCQA knowledge and Office Suite skills are a plus.

Qualifications

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

Responsibilities

• Perform utilization management including prior authorization and retrospective review.
• Review provider requests requiring authorization and coordinate approvals/denials.
• Conduct pre-certification and care coordination for appropriate treatment.
• Ensure compliance with CMS/state medical policy and contracts.
• Communicate decisions to members and providers in writing or verbally.

Skills

Oral & written communication

Interpersonal skills

Problem-solving

Analytical skills

Facilitation skills

Microsoft Word/Excel/Outlook

Education

RN license

BSN preferred

Tools

Microsoft Office

Job description

Sentara Health Plans Community Care in Norfolk, VA is seeking a licensed RN for our Utilization Review team. This role performs prior authorization, retrospective review, medical director referrals, and care coordination to ensure appropriate treatment and policy compliance.

Requirements include RN licensure, BSN preferred, and at least 3 years of acute care experience. Milliman/NCQA knowledge and Office Suite skills are a plus.