Utilization Review Nurse, RN

Sentara Health

Utilization Review RN managing Medicaid authorizations and care transitions for Sentara Health Plans. Applying clinical criteria, coordinating reviews, and supporting members across eligible U.S.

Posted 8/14/2026full-timeRemote • Alabama, Florida, Idaho, Kansas, Louisiana, Maine, Maryland, Minnesota, Nevada, New Hampshire, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming • 🇺🇸 United StatesMid-LevelSenior💰 $66,830 - $111,384 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting prior authorization, utilization review, and care coordination while ensuring compliance with medical policies and regulatory standards. Proficient in managing appeals and facilitating member care transitions with strong communication and analytical skills.

Highest-signal resume keywords

Registered Nurse (RN) LicenseUtilization Review ExperienceAcute Care Clinical ExperienceInterQual or Milliman ExperienceStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prior AuthorizationUtilization ReviewCare CoordinationDischarge PlanningMedical Policy ComplianceAppeals ManagementTreatment-Setting AppropriatenessAnalytical SkillsProblem-Solving SkillsAccreditation Standards

Soft Skills

Interpersonal CommunicationFacilitation Skills

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft OutlookMicrosoft Teams

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

LTSS WaiverMedicaidNCQACMSClinical Criteria

About the role

Key responsibilities & impact

Conduct prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and member/provider approval or denial letters
Review provider requests for services requiring authorization
Conduct pre-certification, continued stay review, care coordination, and discharge planning
Review treatment-setting appropriateness and compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts
Manage appeals for denied services
Provide written and verbal notifications to members and providers
Perform proactive anticipatory discharge planning
Serve as joint transition-of-care coordinator with case management and facilitate member care transitions
Ensure medical director decisions are consistent with CMS, state, medical policy, and clinical criteria
Facilitate accreditation by accurately applying accrediting and regulatory requirements and standards

Requirements

What you’ll need

Registered Nurse (RN) License (Compact or Virginia) REQUIRED
3 years of acute care clinical experience REQUIRED
Previous Utilization Review highly preferred
Previous LTSS Waiver or Medicaid experience highly preferred
InterQual or Milliman experience preferred
Knowledge of NCQA preferred
Strong oral, written, and interpersonal communication skills
Problem-solving, facilitation, and analytical skills
Strong Microsoft skills, including Word, Excel, Outlook, and Teams
Bachelor’s Degree in Nursing preferred
Availability for standard hours of 8am to 5pm EST, Monday through Friday
Weekend and holiday coverage required
Expected to work 13 weekend day shifts per year and assigned holiday coverage
Ability to work in one of the listed eligible states

Benefits

Comp & perks

Medical, Dental, Vision plans
Adoption, Fertility and Surrogacy Reimbursement up to $10,000
Paid Time Off and Sick Leave
Paid Parental & Family Caregiver Leave
Emergency Backup Care
Long-Term, Short-Term Disability, and Critical Illness plans
Life Insurance
401k/403B with Employer Match
Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
Student Debt Pay Down – $10,000
Pet Insurance
Legal Resources Plan
Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met
Market-competitive compensation packages inclusive of base pay, incentives, and benefits
Professional development and continued employment philosophy