Utilization Review RN — Care Coordination & Approvals

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

Benefits offered by this job

Adoption, Fertility and Surrogacy Reim

Emergency Backup Care

Long-Term, Short-Term Disability

Life Insurance

Legal Resources Plan

Annual discretionary bonus if criteria

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse to perform utilization management, including prior authorizations, retrospective reviews, and medical director referrals. The role requires RN licensure and at least 3 years of acute care experience.

The position involves pre-certification, care coordination for treatment appropriateness, and adherence to criteria and policies. It supports accreditation efforts and regulatory compliance within Sentara Health.

Qualifications

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

Responsibilities

• Perform utilization management activities including prior authorization, retrospective review, and referrals to medical director; issue approvals/denials to members/providers.
• Conduct pre-certification and care coordination to ensure appropriateness of treatment; set reviews to ensure compliance with criteria and policies.
• Ensure medical director decisions align with CMS, state, and policy requirements; support accreditation efforts by applying regulatory standards.

Skills

Care coordination

Prior authorization

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking an Utilization Review Nurse to perform utilization management, including prior authorizations, retrospective reviews, and medical director referrals. The role requires RN licensure and at least 3 years of acute care experience.

The position involves pre-certification, care coordination for treatment appropriateness, and adherence to criteria and policies. It supports accreditation efforts and regulatory compliance within Sentara Health.