Utilization Review Nurse — Remote Options

Sentara Health; Norfolk (VA); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k match

Paid time off

Parental leave

Student loan repayment

Tuition assistance

Pet insurance

Life insurance

Disability insurance

Annual bonus

Job summary

Sentara Health Plans Community Care seeks a Utilization Review Nurse (RN) in Norfolk, VA. The role supports utilization management, including prior authorization, pre-certification, and care coordination to ensure treatment aligns with medical policy and member contracts.

Required RN licensure with 3 years of acute care experience; BSN preferred. Milliman and NCQA knowledge are pluses; strong communication and analytical skills are essential.

Qualifications

• RN license required
• 3 years of acute care clinical experience required
• Milliman experience preferred
• Knowledge of NCQA preferred
• Microsoft Suite experience preferred

Responsibilities

• Perform utilization management including prior authorization and retrospective review
• Coordinate care, ensure treatment aligns with criteria and policy
• Prepare and communicate approvals or denials to members/providers
• Ensure compliance with accrediting and regulatory requirements

Skills

Communication skills

Problem-solving

Facilitation

Analytical skills

Education

BSN preferred

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care seeks a Utilization Review Nurse (RN) in Norfolk, VA. The role supports utilization management, including prior authorization, pre-certification, and care coordination to ensure treatment aligns with medical policy and member contracts.

Required RN licensure with 3 years of acute care experience; BSN preferred. Milliman and NCQA knowledge are pluses; strong communication and analytical skills are essential.