Utilization Review RN — Care Coordination & Denials Expert

Sentara Health; Town of King (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 and Holidays

Educational assistance or student loan

Student Debt Pay Down

Life Insurance

Disability plans

Tuition Assistance - Guild Education

Job summary

Sentara Health Plans Community Care is hiring a Utilization Review Nurse. This role manages utilization management services within licensure, including prior authorization, pre-certification, and care coordination to ensure appropriate treatment and policy compliance.

Requirements include RN license and BSN preferred, with 3+ years acute care experience and familiarity with Milliman and NCQA. Strong communication and analytical skills are essential.

Qualifications

• RN license required; BSN preferred.
• 3+ years acute care clinical experience; utilization review experience preferred.
• Milliman knowledge preferred; NCQA knowledge helpful.
• Proficient with Microsoft Office; strong communication and analytical skills.

Responsibilities

• Perform utilization management services including prior authorization, retrospective review, and care coordination.
• Coordinate pre-certification and ensure compliance with criteria, policies, and contracts.
• Provide written and/or verbal notification to members and providers; ensure consistency with criteria and regulatory standards.
• Apply accrediting and regulatory requirements and standards to practice.

Skills

3 years acute care clinical experience

Utilization Review experience

Strong oral, written and interpersonal

Problem-solving

Facilitation skills

Analytical skills

MS Office proficiency

Education

BSN (preferred)

Tools

Milliman

Microsoft Office (Excel, Word, Outlook)

Job description

Sentara Health Plans Community Care is hiring a Utilization Review Nurse. This role manages utilization management services within licensure, including prior authorization, pre-certification, and care coordination to ensure appropriate treatment and policy compliance.

Requirements include RN license and BSN preferred, with 3+ years acute care experience and familiarity with Milliman and NCQA. Strong communication and analytical skills are essential.