Utilization Review Nurse: Pre-Cert & Care Coordination

Sentara Health; Oregon; Hybrid; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off and Holidays

401k/403b with employer match

Tuition Assistance

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse to join our team in Norfolk, VA. You will perform utilization management activities, including prior authorization, retro reviews, and care coordination to ensure appropriate treatment and compliance with policies and regulations.

The role requires an RN license with at least 3 years of acute care experience; BSN is preferred. Strong communication and analytical skills are essential, along with experience in Milliman and

Qualifications

• 3 years of acute care clinical experience (required)
• Registered Nurse license required
• BSN preferred

Responsibilities

• Perform utilization management services within licensure scope.
• Handle prior authorization, retrospective review, and medical director referrals.
• Coordinate care and pre-certification, ensuring appropriateness of treatment.
• Notify members and providers with written/verbal decisions.
• Apply CMS, state, medical policy criteria and ensure regulatory compliance.

Skills

Oral communication

Written communication

Analytical skills

Facilitation

Problem-solving

Education

RN license

BSN (preferred)

Tools

Milliman experience

NCQA knowledge

Microsoft Word

Microsoft Excel

Outlook

Job description

Sentara Health Plans Community Care is seeking an Utilization Review Nurse to join our team in Norfolk, VA. You will perform utilization management activities, including prior authorization, retro reviews, and care coordination to ensure appropriate treatment and compliance with policies and regulations.

The role requires an RN license with at least 3 years of acute care experience; BSN is preferred. Strong communication and analytical skills are essential, along with experience in Milliman and