RN Utilization Review Specialist – Acute Care & Pre-Cert

Sentara Health; Clifton (TX); 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

Tuition Assistance

Student Debt Pay Down

Life Insurance

Job summary

Sentara Health Plans Community Care seeks an experienced Utilization Review Nurse to join our Norfolk, VA team. The role covers prior authorization, retrospective review, care coordination, and adherence to medical policy and regulatory criteria.

You will communicate decisions to members and providers, prepare denial/approval letters, and support accreditation efforts while applying NCQA and CMS criteria in daily decisions. BSN preferred; RN required.

Qualifications

• 3 years of acute care clinical experience required.
• Utilization Review experience preferred.
• Knowledge of NCQA preferred.
• Experience with Milliman and MS Office preferred.

Responsibilities

• Perform utilization management including prior authorization and retrospective review.
• Facilitate patient/provider approval or denial letters per criteria.
• Review service requests requiring authorization and coordinate pre-certification.
• Ensure compliance with CMS, state, and policy criteria and member eligibility.
• Communicate decisions to members and providers; maintain documentation.
• Support accreditation by applying regulatory standards.

Skills

Oral communication

Written communication

Interpersonal skills

Problem-solving

Facilitation

Analytical skills

Education

BSN

Registered Nurse (RN)

Tools

Milliman

Microsoft Office

Job description

Sentara Health Plans Community Care seeks an experienced Utilization Review Nurse to join our Norfolk, VA team. The role covers prior authorization, retrospective review, care coordination, and adherence to medical policy and regulatory criteria.

You will communicate decisions to members and providers, prepare denial/approval letters, and support accreditation efforts while applying NCQA and CMS criteria in daily decisions. BSN preferred; RN required.