RN Utilization Review Specialist - Care Coordination & Compliance

Sentara Health; Oklahoma City (OK); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical plans

Dental plans

Vision plans

Tuition assistance

401k/403B with employer match

Job summary

Sentara Health is seeking a Utilization Review Nurse in Norfolk, VA. The role focuses on utilization management, prior authorization, care coordination, and adherence to medical policy and regulatory standards.

The ideal candidate has an RN license, a BSN preferred, and at least 3 years of acute care experience. Strong communication and analytical skills are essential to succeed in this position.

Qualifications

• 3 years of acute care clinical experience (required).
• Utilization Review experience and Milliman knowledge preferred.
• Familiar with NCQA standards and clinical criteria.
• Strong written and verbal communication and facilitation skills.

Responsibilities

• Perform prior authorization, retrospective review, and medical director referrals.
• Coordinate care and pre-certification to ensure treatment appropriateness.
• Notify members/providers of decisions and ensure compliance with policy.

Skills

Oral and written communication

Interpersonal skills

Analytical skills

Problem-solving

Facilitation skills

Education

BSN (preferred)

RN certification (required)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health is seeking a Utilization Review Nurse in Norfolk, VA. The role focuses on utilization management, prior authorization, care coordination, and adherence to medical policy and regulatory standards.

The ideal candidate has an RN license, a BSN preferred, and at least 3 years of acute care experience. Strong communication and analytical skills are essential to succeed in this position.