UTILIZATION REVIEW NURSE

Sentara Health

10d • $93,184 - $136,947

About The Position

Sentara Health Plans Community Care is seeking a Utilization Review Nurse to provide utilization management services within the scope of licensure. The role includes prior authorization, retrospective review, medical director referrals, and issuing member and provider approval or denial notifications. The nurse reviews provider requests for services requiring authorization and conducts pre-certification and care coordination to assess treatment appropriateness. Reviews ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.

The nurse provides written and/or verbal notifications to members and providers, and ensures medical director decisions are consistent with applicable criteria, including CMS, state, medical policy, and clinical criteria. The role also supports accreditation by understanding, interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

• Registered Nurse certification is required.
• At least 3 years of acute care clinical experience is required.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving, facilitation, and analytical skills.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Previous Utilization Review experience.
• Milliman experience.
• Knowledge of NCQA.
• Microsoft Word, Excel, and Outlook experience.

Responsibilities

• Conduct prior authorization and retrospective reviews.
• Refer cases to medical directors and execute member and provider approval or denial notifications.
• Review provider requests for services requiring authorization.
• Conduct pre-certification and care coordination to assess treatment appropriateness.
• Review cases for compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.
• Provide written and/or verbal notifications to members and providers.
• Ensure medical director written decisions are consistent with CMS, state, medical policy, and clinical criteria.
• Support accreditation by interpreting and applying accrediting and regulatory requirements and standards.

Benefits

• Medical, dental, and vision plans.
• Adoption, fertility, and surrogacy reimbursement up to $10,000.
• Paid time off and sick leave.
• Paid parental and family caregiver leave.
• Emergency backup care.
• Long-term and short-term disability and critical illness plans.
• Life insurance.
• 401(k)/403(b) with employer match.
• Tuition assistance up to $5,250 per year and discounted educational opportunities through Guild Education.
• Student debt pay down up to $10,000.
• Pet insurance.
• Legal resources plan.
• Opportunity to earn an annual discretionary bonus, subject to system and employee eligibility criteria.
• Paid holidays.
• Paid military leave.
• Educational assistance or student loan repayment.
• Voluntary benefits.
• Market-competitive compensation package that may include incentives and additional compensation such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed