RN Utilization Review Nurse — Care Coordination

Sentara Health; Norfolk (VA); 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

Paid Parental & Family Caregiver Leave

Emergency Backup Care

Disability and Critical Illness plans

Life Insurance

401k/403B with Employer Match

Tuition Assistance – Guild Education

Student Debt Pay Down – $10,000

Pet Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plans Community Care seeks a Utilization Review Nurse in Norfolk, VA to manage utilization management, including prior authorization, retrospective review, and care coordination for appropriate treatment. The role requires an RN license, preferably a BSN, with at least 3 years of acute care experience.

Familiarity with Milliman and NCQA is preferred; strong communication and analytical skills are essential.

Qualifications

• 3 years of acute care clinical experience (required).
• Registered Nurse (required).
• BSN (preferred).
• Milliman experience (preferred).
• Knowledge of NCQA (preferred).
• Microsoft Office (Word, Excel, Outlook) (preferred).

Responsibilities

• Performs utilization management services within the scope of licensure.
• Conducts prior authorization, retrospective review, and care coordination for appropriateness of treatment.
• Reviews provider requests for services requiring authorization and communicates decisions.
• Ensures decisions are consistent with CMS, state, and policy criteria.

Education

RN (required)

BSN (preferred)

Tools

Microsoft Office

Milliman

NCQA knowledge

Job description

Sentara Health Plans Community Care seeks a Utilization Review Nurse in Norfolk, VA to manage utilization management, including prior authorization, retrospective review, and care coordination for appropriate treatment. The role requires an RN license, preferably a BSN, with at least 3 years of acute care experience.

Familiarity with Milliman and NCQA is preferred; strong communication and analytical skills are essential.