Utilization Review Nurse - RN, Care Coordination & Compliance

Sentara Health; Beryl (WV); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403b with employer match

Paid Time Off

Parental and Military leave

Educational assistance

Student loan repayment

Tuition assistance

Life Insurance

Disability plans

Pet Insurance

Job summary

Sentara Health Plans Community Care is hiring a Utilization Review Nurse in Norfolk, VA. The role conducts prior authorization, retrospective review, and care coordination to ensure treatment appropriateness and compliance with policy and accrediting standards.

The ideal candidate has a BSN (preferred) and an RN license, with at least 3 years of acute care experience and familiarity with Milliman, NCQA, and Microsoft Office. Strong communication and analytical skills are essential.

Qualifications

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

Responsibilities

• Provides utilization management services within the scope of licensure.
• Performs prior authorization, retrospective review, and medical director referrals and denial communications.
• Reviews provider requests for services requiring authorization.
• Conducts pre-certification and care coordination for treatment appropriateness.
• Ensures compliance with criteria, medical policy, and member eligibility/benefits/contracts.
• Notifies members and providers in writing or verbally of decisions.
• Ensures decisions align with accrediting/regulatory requirements and standards.

Skills

Oral communication

Written communication

Interpersonal skills

Problem-solving

Facilitation skills

Analytical skills

Education

BSN preferred

RN license

Tools

Microsoft Office

Job description

Sentara Health Plans Community Care is hiring a Utilization Review Nurse in Norfolk, VA. The role conducts prior authorization, retrospective review, and care coordination to ensure treatment appropriateness and compliance with policy and accrediting standards.

The ideal candidate has a BSN (preferred) and an RN license, with at least 3 years of acute care experience and familiarity with Milliman, NCQA, and Microsoft Office. Strong communication and analytical skills are essential.