UTILIZATION REVIEW NURSE
Sentara Health
Summary
Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse.
Job description
Overview
Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse.
The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conducts pre-certification, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Responsible for written and/or verbal notification to members and providers. Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Education
- BSN (preferred)
Certification
- Registered Nurse (required)
Experience
- 3 years of acute care clinical experience (required)
- Previous Utilization Review experience (preferred)
- Milliman experience (preferred)
- Knowledge of NCQA (preferred)
- Microsoft suite (Word, Excel, Outlook) (preferred)
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Requirements
- Registered Nurse (required)
- 3 years of acute care clinical experience (required)
- BSN (preferred)
- Previous Utilization Review experience (preferred)
- Milliman experience (preferred)
- Knowledge of NCQA (preferred)
- Microsoft suite (Word, Excel, Outlook) (preferred)
- Strong oral, written and interpersonal communication skills
- Problem-solving skills
- Facilitation skills
- Analytical skills
Benefits
- Medical, Dental & Vision
- Life & Disability Insurance
- 401(k)/403(b) Matching
- Paid Time Off
- Paid Parental Leave
- Paid Military Leave
- Educational Assistance
- Student Loan Repayment
- Adoption Reimbursement
- Fertility Reimbursement
- Surrogacy Reimbursement
- Emergency Backup Care
- Pet Insurance
- Legal Resources Plan
- Annual Discretionary Bonus
Company overview
Sentara Health is a leading not-for-profit integrated healthcare delivery system serving Virginia, northeastern North Carolina, and Florida. Founded in 1888 and headquartered in Hampton Roads, Virginia, Sentara operates 12 acute care hospitals across its service area, with 10 hospitals holding prestigious Magnet® recognition for nursing excellence. The organization employs approximately 34,000 healthcare professionals and serves over 1 million health plan members through its Sentara Health Plans division. As one of the top 20 largest not-for-profit integrated health systems in the United States, Sentara is nationally recognized for clinical quality, safety, and innovation. The system has received numerous accolades including Health Quality Innovator of the Year (2024), Forbes' "America's Best-In-State Employer" (2024), and inclusion in IBM Watson Health's "Top 15 Health Systems." Sentara's comprehensive services span hospital care, outpatient facilities, home health, hospice services, and specialized programs like the Nightingale air ambulance service, which has completed over 20,000 missions since 1982.