RN Utilization Review Specialist: Care Coordination

Sentara Health Plans; Norfolk, Northern (VA, KY); Hybrid; USD 65,000 - 85,000; 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

Long-Term, Short-Term Disability, and

Life Insurance

401k/403B with Employer Match

Tuition Assistance – $5,250/year

Student Debt Pay Down – $10,000

Pet Insurance

Legal Resources Plan

Job summary

Sentara Health Plans Community Care in Norfolk, VA seeks an Utilization Review Nurse to manage utilization management within licensure. You will handle prior authorization, retrospective review, and pre-certification while coordinating care and communicating decisions to members and providers.

The role requires a RN license, 3 years of acute care experience, and familiarity with Milliman and NCQA standards.

Qualifications

• BSN preferred.
• RN certification required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Word, Excel, and Outlook experience preferred.

Responsibilities

• Utilization management services within licensure.
• Perform prior authorization, retrospective review, and referrals.
• Review provider requests requiring authorization and issuance of decisions.
• Conduct pre-certification and care coordination for treatment appropriateness.
• Ensure reviews comply with criteria, policy, and member contracts.
• Notify members and providers in writing or verbally.
• Ensure medical director decisions align with CMS/state/clinical criteria and standards.

Skills

Prior authorization

Care coordination

Discharge planning

Case management

Microsoft suite knowledge

Education

BSN (preferred)

Registered Nurse (required)

Tools

Milliman

NCQA knowledge

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care in Norfolk, VA seeks an Utilization Review Nurse to manage utilization management within licensure. You will handle prior authorization, retrospective review, and pre-certification while coordinating care and communicating decisions to members and providers.

The role requires a RN license, 3 years of acute care experience, and familiarity with Milliman and NCQA standards.