Utilization Review Nurse - Care Coordination & Compliance

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

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.