RN Utilization Review Specialist — Care Coordination & Compliance

Sentara Health; Lincoln (NE); 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 and Holidays

Parental and Family Caregiver Leave

Tuition Assistance

Job summary

Sentara Health Plans Community Care in Norfolk, VA is seeking a Utilization Review Nurse (RN) to perform utilization management, including prior authorization, retrospective review, and care coordination for appropriate treatment. You will notify members and providers, apply CMS/state policies, and ensure regulatory compliance.

This role emphasizes collaboration with medical directors and adherence to NCQA and other standards. Requirements include a BSN preferred and RN licensure.

Qualifications

• BSN preferred and RN licensure required.
• 3 years of acute care clinical experience required.
• Utilization Review and Milliman/NCQA familiarity preferred.
• Strong oral, written, and interpersonal communication skills.

Responsibilities

• Conduct utilization management including prior authorization and retrospective review.
• Coordinate care and ensure treatment is appropriate and compliant with criteria.
• Notify members and providers with written or verbal decisions.
• Apply CMS/state criteria, medical policy, and regulatory standards; interact with medical directors.

Skills

Communication skills

Analytical skills

Problem solving

Facilitation skills

Education

BSN (preferred)

Tools

Microsoft Office

Job description

Sentara Health Plans Community Care in Norfolk, VA is seeking a Utilization Review Nurse (RN) to perform utilization management, including prior authorization, retrospective review, and care coordination for appropriate treatment. You will notify members and providers, apply CMS/state policies, and ensure regulatory compliance.

This role emphasizes collaboration with medical directors and adherence to NCQA and other standards. Requirements include a BSN preferred and RN licensure.