Utilization Review Nurse, RN – Imaging

Sentara Health

Utilization Review RN managing imaging authorizations, inpatient reviews, and appeals for Sentara Health Plans. Coordinating member transitions and applying clinical, regulatory, and medical-policy criteria.

Posted 8/25/2026full-timeRemote • Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $66,830 - $111,384 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Review, including prior authorization, concurrent review, and care coordination, while ensuring compliance with medical policies and regulatory standards. Proficient in managing appeals and facilitating member care transitions within the healthcare system.

Highest-signal resume keywords

Registered Nurse (RN) LicenseUtilization Review ExperienceAcute Care Clinical ExperienceInterQual or Milliman ExperienceKnowledge of NCQA

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prior AuthorizationConcurrent ReviewRetrospective ReviewCare CoordinationDischarge PlanningMedical Policy ComplianceAppeals ManagementTreatment Setting ReviewsMember Eligibility AssessmentClinical Criteria Application

Soft Skills

Effective CommunicationProactive PlanningCollaboration

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

CMS ComplianceAccrediting StandardsNCQAMedical Director ReferralsInpatient ReviewProvider RequestsMember/Provider NotificationsUtilization Review Knowledge

About the role

Key responsibilities & impact

Conduct primary functions of 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
Ensure treatment setting reviews comply with applicable criteria, medical policy, member eligibility, benefits, and contracts
Manage appeals for denied services
Provide written and verbal notifications to members and providers
Demonstrate proactive anticipatory discharge planning
Serve as joint transition-of-care coordinator with case management and facilitate member care transitions
Ensure medical director written decisions are consistent with CMS, state, medical policy, and clinical criteria
Apply accrediting and regulatory requirements and standards accurately
Utilize management services within the scope of licensure

Requirements

What you’ll need

Registered Nurse (RN) License (Compact or Virginia) REQUIRED
3 years of acute care clinical experience REQUIRED
Bachelor's Degree in Nursing preferred
Previous Utilization Review experience highly preferred
Previous imaging experience preferred
InterQual or Milliman experience preferred
Knowledge of NCQA preferred
Ability to work 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
Utilization review knowledge within scope of licensure

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
Annual discretionary bonus opportunity subject to established system and employee eligibility criteria
Shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities may be available
Family-friendly culture
Opportunities for development and growth
Tobacco-free environment