RN Utilization Review & Care Coordination

sentara; United States; 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

Tuition Assistance

Discretionary Bonus eligibility

Job summary

Sentara Health Plans Community Care in Norfolk, VA is seeking a Utilization Review Nurse. The role involves utilization management, prior authorization, and care coordination to ensure treatment is appropriate and compliant with medical policy and member contracts.

Requires RN licensure and BSN preferred, with at least 3 years of acute care experience; Milliman, NCQA knowledge, and MS Office skills are plus. The position offers competitive pay and comprehensive benefits.

Qualifications

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

Responsibilities

• Performs utilization management activities including prior authorization, retrospective review, and medical director referrals.
• Reviews provider requests for services requiring authorization and conducts pre-certification.
• Engages in care coordination for appropriateness of treatment and sets reviews to ensure criteria compliance.
• Issues written and/or verbal notifications to members and providers.
• Ensures decisions align with CMS, state, medical policy, and contract terms; supports accreditation efforts.

Skills

Oral communication

Written communication

Interpersonal skills

Analytical skills

Problem-solving skills

Facilitation skills

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care in Norfolk, VA is seeking a Utilization Review Nurse. The role involves utilization management, prior authorization, and care coordination to ensure treatment is appropriate and compliant with medical policy and member contracts.

Requires RN licensure and BSN preferred, with at least 3 years of acute care experience; Milliman, NCQA knowledge, and MS Office skills are plus. The position offers competitive pay and comprehensive benefits.