Utilization Review Nurse: Care Coordination & Compliance

Sentara Health; Charleston (WV); 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

Tuition Assistance

Student Debt Pay Down

Life Insurance

Disability coverage

Educational assistance or student loan

Paid parental leave

Job summary

Sentara Health Plans Community Care seeks a full-time Utilization Review Nurse in Norfolk, VA. You will conduct utilization management activities, including prior authorizations, retrospective reviews, and care coordination to ensure appropriate treatment and policy compliance.

Qualified candidates hold RN licensure (BSN preferred) with 3 years of acute care experience; Milliman/NCQA knowledge is a plus, and strong communication skills are essential for provider and member interactions.

Qualifications

• RN license is required.
• BSN (preferred).
• 3 years of acute care clinical experience required.
• Utilization Review experience preferred.
• Milliman and NCQA knowledge preferred.

Responsibilities

• Perform utilization management within licensure scope.
• Handle prior authorizations and retrospective reviews.
• Facilitate medical director referrals and denial/approval notifications.
• Coordinate care and ensure treatment aligns with criteria and policy.
• Communicate clearly with members and providers per accreditation standards.

Skills

Utilization review

Care coordination

Prior authorization

Communication skills

Problem solving

Interpersonal skills

Microsoft Office

Education

RN licensure (required)

Tools

Milliman

NCQA

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care seeks a full-time Utilization Review Nurse in Norfolk, VA. You will conduct utilization management activities, including prior authorizations, retrospective reviews, and care coordination to ensure appropriate treatment and policy compliance.

Qualified candidates hold RN licensure (BSN preferred) with 3 years of acute care experience; Milliman/NCQA knowledge is a plus, and strong communication skills are essential for provider and member interactions.