Utilization Review RN for Care Coordination & Compliance

Sentara Health; Seattle (WA); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Adoption, Fertility and Surrogacy Reim

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Emergency Backup Care

Long-Term Disability

Short-Term Disability

401k/403B with Employer Match

Tuition Assistance

Student Debt Pay Down

Pet Insurance

Legal Resources Plan

Job summary

Sentara Health Plans Community Care is seeking an experienced Utilization Review Nurse to perform prior authorization, retrospective review, and care coordination within licensure scope.

You will review provider requests for services requiring authorization, conduct pre-certification, and ensure treatment aligns with medical policy and CMS/NCQA criteria. Strong communication and problem-solving skills are essential.

Qualifications

• BSN preferred; RN licensure required.
• Minimum 3 years of acute care clinical experience.
• Prior utilization review experience preferred.
• Familiarity with Milliman and NCQA encouraged.
• Proficient in Microsoft Office suite and communication skills.

Responsibilities

• Conduct prior authorization, retrospective review, and care coordination.
• Review provider requests for services requiring authorization.
• Perform pre-certification and ensure compliance with policy, criteria, and contracts.
• Notify members and providers of outcomes in writing or verbally.

Skills

Acute care experience

Utilization Review experience

Milliman experience

NCQA knowledge

Microsoft Office

Communication skills

Problem-solving

Analytical skills

Education

BSN (preferred)

Registered Nurse (required)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Sentara Health Plans Community Care is seeking an experienced Utilization Review Nurse to perform prior authorization, retrospective review, and care coordination within licensure scope.

You will review provider requests for services requiring authorization, conduct pre-certification, and ensure treatment aligns with medical policy and CMS/NCQA criteria. Strong communication and problem-solving skills are essential.