Utilization Review RN - Care Coordination & Compliance

Sentara Health; Madison (WI); 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

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse in Norfolk, VA. The RN will manage utilization management, prior authorizations, and care coordination to ensure appropriate treatment and policy compliance. Strong communication and analytical skills are essential.

Required RN licensure with 3 years of acute care experience; BSN preferred. Milliman and NCQA knowledge are a plus. Competitive benefits and base pay are included, with potential for additional compensation

Qualifications

• RN licensure required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Proficient in Microsoft Office suite.

Responsibilities

• Conducts utilization management services including prior authorization, retrospective review, and care coordination.
• Performs pre-certification and facilitates approval/denial communications with members and providers.
• Ensures compliance with CMS, state, and medical policy criteria and regulatory standards.

Skills

Oral & Written Communication

Interpersonal Skills

Problem-Solving

Facilitation Skills

Analytical Skills

Care Coordination

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking a Utilization Review Nurse in Norfolk, VA. The RN will manage utilization management, prior authorizations, and care coordination to ensure appropriate treatment and policy compliance. Strong communication and analytical skills are essential.

Required RN licensure with 3 years of acute care experience; BSN preferred. Milliman and NCQA knowledge are a plus. Competitive benefits and base pay are included, with potential for additional compensation