Remote Utilization Review RN – Imaging/Commercial

Sentara Health; Virginia (IL); On-site; USD 67,000 - 111,000; Full time

Benefits offered by this job

Medical benefits

Dental & Vision

401k with match

Tuition assistance

Student debt payoff

Job summary

Sentara Health Plans is seeking an experienced Utilization Review Nurse (RN) for Imaging/Commercial with remote work eligibility. The role covers prior authorization, inpatient and concurrent review, and coordination of care across benefits and contracts.

A Virginia-compact or Virginia RN license is required, with a strong preference for imaging and NCQA knowledge. The position supports a 40-hour week with flexible weekend/holiday coverage.

Qualifications

• Bachelor's degree in Nursing preferred.
• RN license (Compact or Virginia) required.
• Minimum 3 years of acute care clinical experience.
• Prior utilization review and imaging experience preferred.
• Knowledge of NCQA preferred.

Responsibilities

• Utilization Review Nurse conducts prior authorization, inpatient and concurrent reviews, and member/provider approvals/denials.
• Performs pre-certification, continued stay review, care coordination, and discharge planning.
• May manage appeals and notify members/providers of decisions.
• Acts as joint transition of care coordinator with case management.
• Ensures decisions align with CMS, state, and clinical policy criteria.

Skills

Acute care experience

Utilization review experience

Imaging experience

InterQual/Milliman knowledge

NCQA knowledge

Education

Bachelor's degree in Nursing

Tools

InterQual

Milliman

Job description

Sentara Health Plans is seeking an experienced Utilization Review Nurse (RN) for Imaging/Commercial with remote work eligibility. The role covers prior authorization, inpatient and concurrent review, and coordination of care across benefits and contracts.

A Virginia-compact or Virginia RN license is required, with a strong preference for imaging and NCQA knowledge. The position supports a 40-hour week with flexible weekend/holiday coverage.