Utilization Review RN: Care Coordination & Compliance

Sentara Health; Manchester (NH); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Adoption, Fertility and Surrogacy Reim

Paid Time Off and Sick Leave

Parental & Family Caregiver Leave

Emergency Backup Care

Disability plans (Long/Short-Term, etc

Life Insurance

401k/403B with Employer Match

Tuition Assistance – $5,250/year

Student Debt Pay Down – $10,000

Pet Insurance

Legal Resources Plan

Job summary

Sentara Health Plans Community Care is hiring a Utilization Review Nurse to manage utilization management within licensure. Responsibilities include prior authorization, retrospective review, and care coordination, with notification to members/providers. Ensures decisions align with CMS, medical policy, and contracts.

Requirements include RN license, BSN preferred, and 3 years acute care experience. Milliman/NCQA knowledge and MS Office skills are a plus.

Qualifications

• RN license is required.
• BSN preferred.
• 3 years of acute care clinical experience required.
• Utilization Review experience and Milliman/NCQA knowledge are preferred.
• Proficient in MS Office suite.

Responsibilities

• Perform utilization management services within licensure scope.
• Conduct prior authorization, retrospective review, and care coordination.
• Notify members and providers of decisions and ensure compliance with criteria and contracts.
• Apply accrediting and regulatory requirements accurately.

Skills

Strong communication

Problem-solving

Facilitation

Analytical skills

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is hiring a Utilization Review Nurse to manage utilization management within licensure. Responsibilities include prior authorization, retrospective review, and care coordination, with notification to members/providers. Ensures decisions align with CMS, medical policy, and contracts.

Requirements include RN license, BSN preferred, and 3 years acute care experience. Milliman/NCQA knowledge and MS Office skills are a plus.