Utilization Review Nurse

sentara; United States; On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k with Employer Match

Paid Time Off

Tuition Assistance

Discretionary Bonus eligibility

Job summary

Sentara Health Plans Community Care in Norfolk, VA is seeking a Utilization Review Nurse. The role involves utilization management, prior authorization, and care coordination to ensure treatment is appropriate and compliant with medical policy and member contracts.

Requires RN licensure and BSN preferred, with at least 3 years of acute care experience; Milliman, NCQA knowledge, and MS Office skills are plus. The position offers competitive pay and comprehensive benefits.

Qualifications

• RN license required.
• 3 years of acute care clinical experience.
• Utilization Review experience preferred.
• Milliman experience preferred.
• Knowledge of NCQA preferred.
• Microsoft Office suite proficiency preferred.

Responsibilities

• Performs utilization management activities including prior authorization, retrospective review, and medical director referrals.
• Reviews provider requests for services requiring authorization and conducts pre-certification.
• Engages in care coordination for appropriateness of treatment and sets reviews to ensure criteria compliance.
• Issues written and/or verbal notifications to members and providers.
• Ensures decisions align with CMS, state, medical policy, and contract terms; supports accreditation efforts.

Skills

Oral communication

Written communication

Interpersonal skills

Analytical skills

Problem-solving skills

Facilitation skills

Education

BSN (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

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.

Compensation

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, standby/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.

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.

Equal Opportunity Statement

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.