Utilization Review RN — Care Coordination & Compliance

Sentara Health; Nevada; 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 and holidays

Education assistance

Job summary

Sentara Health Plans Community Care is seeking an Utilization Review Nurse (RN) in Norfolk, VA. The role covers utilization management, prior authorization, and care coordination to ensure treatment aligns with clinical criteria and policy. Strong communication and analytical skills are essential.

Qualifications include RN licensure, BSN preferred, and at least 3 years of acute care experience. Milliman experience and NCQA knowledge are desirable.

Qualifications

• 3 years of acute care clinical experience (required).
• Utilization Review experience (preferred).
• Milliman experience (preferred).
• Knowledge of NCQA (preferred).
• Microsoft Office Suite (Word, Excel, Outlook) preferred.

Responsibilities

• Perform utilization management services including prior authorization, retrospective review, and medical director referrals.
• Review provider requests for services requiring authorization and perform pre-certification activities.
• Coordinate care for appropriateness of treatment and ensure compliance with criteria, policy, and contracts.
• Communicate decisions to members and providers in writing or verbally and support accreditation activities.

Skills

Acute care experience

Milliman

NCQA knowledge

Microsoft Office Suite

Communication skills

Problem-solving

Facilitation skills

Analytical skills

Education

BSN (preferred)

Tools

Microsoft Office

Job description

Sentara Health Plans Community Care is seeking an Utilization Review Nurse (RN) in Norfolk, VA. The role covers utilization management, prior authorization, and care coordination to ensure treatment aligns with clinical criteria and policy. Strong communication and analytical skills are essential.

Qualifications include RN licensure, BSN preferred, and at least 3 years of acute care experience. Milliman experience and NCQA knowledge are desirable.