RN Utilization Review & Prior Authorization Specialist

Sentara Health Administration, Inc.; Norfolk (VA); On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Adoption reimbursement up to $10,000

PTO & Sick Leave

Parental & Family Caregiver Leave

Long/Short-term Disability

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse in Norfolk, VA. The role conducts utilization management, including prior authorization, retrospective review, and care coordination to ensure treatment aligns with policy and criteria.

The ideal candidate holds RN licensure with a BSN preferred, and has 3 years of acute care experience. Milliman and MS Office skills are advantageous in this role.

Qualifications

• 3 years of acute care clinical experience required.
• Previous Utilization Review experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office suite (Word, Excel, Outlook) preferred.

Responsibilities

• Perform utilization management services including pre-certification and prior authorization.
• Coordinate care coordination for appropriate treatment and criteria compliance.
• Review requests requiring authorization and communicate decisions to members/providers.
• Ensure adherence to CMS, state, and clinical policy criteria.

Skills

Oral communication

Written communication

Interpersonal skills

Problem-solving

Analytical skills

Facilitation skills

Education

RN licensure

BSN preferred

Tools

Microsoft Excel

Milliman

Job description

Sentara Health Plans Community Care is seeking an Utilization Review Nurse in Norfolk, VA. The role conducts utilization management, including prior authorization, retrospective review, and care coordination to ensure treatment aligns with policy and criteria.

The ideal candidate holds RN licensure with a BSN preferred, and has 3 years of acute care experience. Milliman and MS Office skills are advantageous in this role.