Utilization Review Nurse - Care Coordination & Compliance

Sentara Health; West Virginia; On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) with employer match

Paid time off

Job summary

Sentara Health Plans Community Care seeks a Utilization Review Nurse in Norfolk, VA. The role focuses on utilization management, including prior authorization, retrospective review, and care coordination to ensure treatment appropriateness and policy compliance.

Requires BSN (preferred) and RN licensure with at least 3 years of acute care experience. Milliman and NCQA knowledge are valued; strong communication and analytical skills are essential.

Qualifications

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

Responsibilities

• Conduct utilization management services within licensure.
• Perform prior authorization and retrospective review; manage approvals/denials.
• Coordinate care and ensure compliance with criteria, policies and contracts.
• Notify members/providers of decisions in written/verbal form; ensure accuracy.
• Support accreditation requirements and regulatory standards integrity.

Skills

Communication skills

Problem-solving

Facilitation

Interpersonal skills

Analytical skills

Education

BSN (preferred)

Registered Nurse (RN)

Tools

Milliman

Microsoft Office (Word, Excel, Outlook)

NCQA knowledge

Job description

Sentara Health Plans Community Care seeks a Utilization Review Nurse in Norfolk, VA. The role focuses on utilization management, including prior authorization, retrospective review, and care coordination to ensure treatment appropriateness and policy compliance.

Requires BSN (preferred) and RN licensure with at least 3 years of acute care experience. Milliman and NCQA knowledge are valued; strong communication and analytical skills are essential.