UTILIZATION REVIEW NURSE

Sentara Health; Sioux Falls (SD); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403(b) with match

Tuition Assistance

Paid Time Off

Leave benefits

Employee discount

Additional bonuses

Job summary

Sentara Health is seeking a Utilization Review Nurse to manage prior authorization, retrospective reviews, and care coordination within licensure scope. The role requires RN licensure and at least three years of acute care experience, with preferred familiarity with Milliman and NCQA guidelines.

Base compensation ranges from $93,184 to $136,947 annually, with potential bonuses and comprehensive benefits. The position is based in Norfolk, VA and emphasizes patient-centric, compliant care delivery.

Qualifications

• RN license required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office (Word, Excel, Outlook) preferred.
• Strong oral and written communication, interpersonal, problem-solving, facilitation and analytical skills.

Responsibilities

• Perform utilization management tasks including prior authorization and retrospective reviews.
• Review provider requests for services requiring authorization.
• Coordinate care and assess appropriateness of treatment.
• Prepare and send member/provider notifications per criteria.
• Ensure decisions align with CMS/state policies and medical policy.
• Support accreditation efforts and regulatory compliance.

Skills

Utilization review

Acute care experience

Communication skills

Problem-solving

Facilitation skills

Analytical skills

Education

BSN (preferred)

Tools

Microsoft Office

Job description

City/State Norfolk, VA

Work Shift First (Days)

Overview: Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse .The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conducts pre-certification, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.Responsible for written and/or verbal notification to members and providers. Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Education

• BSN (preferred)

Certification

• Registered Nurse (required)

Experience

• 3 years of acute care clinical experience (required)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Keywords: Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQA

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $93,184.00 - $136,947.20 annually. Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.

Benefits

• Caring For Your Family and Your Career
• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance - $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down - $10,000
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
• Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce.
• Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission "to improve health every day," this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.