Utilization Review Nurse - RN, Care Coordination

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

Benefits offered by this job

Medical, Dental, Vision plans

401(k) with employer match

Paid Time Off

Job summary

Sentara Health Plans Community Care is seeking a Utilization Review Nurse in Norfolk, VA. The role covers utilization management, prior authorization, prospective and retrospective reviews, and coordination to ensure treatment aligns with medical policies and member eligibility.

The position requires an RN license and BSN is preferred, with at least three years of acute care experience. Milliman and NCQA familiarity are a plus. Excellent communication and analytical skills are essential.

Qualifications

• BSN (preferred)
• Registered Nurse license (required)
• 3 years of acute care clinical experience (required)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Responsibilities

• Conduct utilization management including prior authorization, retrospective review, medical director referrals and care coordination.
• Review service requests for authorization and ensure compliance with CMS/state/medical policy criteria and contracts.
• Provide written or verbal notification to members and providers and support accreditation efforts by applying regulatory standards.

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 is seeking a Utilization Review Nurse in Norfolk, VA. The role covers utilization management, prior authorization, prospective and retrospective reviews, and coordination to ensure treatment aligns with medical policies and member eligibility.

The position requires an RN license and BSN is preferred, with at least three years of acute care experience. Milliman and NCQA familiarity are a plus. Excellent communication and analytical skills are essential.