Utilization Review RN: Care Coordination & Compliance

Sentara Health; Tallahassee (FL); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, dental, vision plans

401k with employer match

Paid time off

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse (RN) to perform utilization management, including pre-certification, care coordination, and authorizations. The role ensures decisions align with CMS, state guidelines and medical policy, while communicating with members and providers.

Requirements include RN licensure; BSN preferred; minimum 3 years acute care experience; familiarity with Milliman, NCQA, and Microsoft Office is preferred.

Qualifications

• RN license is required.
• 3 years of acute care clinical experience is required.
• Experience with utilization review or prior authorization is preferred.

Responsibilities

• Perform utilization management including pre-certification and prior authorization.
• Coordinate care and assess appropriateness of treatment.
• Notify members and providers of decisions and rationale.
• Ensure compliance with CMS, state and policy criteria and document outcomes.

Skills

Acute care experience

Utilization Review

Strong communication

Problem solving

Facilitation

Analytical skills

Milliman knowledge

NCQA knowledge

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking an Utilization Review Nurse (RN) to perform utilization management, including pre-certification, care coordination, and authorizations. The role ensures decisions align with CMS, state guidelines and medical policy, while communicating with members and providers.

Requirements include RN licensure; BSN preferred; minimum 3 years acute care experience; familiarity with Milliman, NCQA, and Microsoft Office is preferred.