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Authorization Utilization Review Jobs in Virginia

Sentara Healthcare

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site +1

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Conducts primary functions of prior authorization, retrospective review, medical director referrals ...

Sentara Health Plans

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site

$65 - $85/hr

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Conducts primary functions of prior authorization, retrospective review, medical director referrals ...

New

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... · Assist in preparing Utilization Review Reports as necessary. · Coordinates and makes ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... · Assist in preparing Utilization Review Reports as necessary. · Coordinates and makes ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... · Assist in preparing Utilization Review Reports as necessary. · Coordinates and makes ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

$26 - $35/hr

... authorizations for residents in treatment. • Ensures coordinated effective resident care ... Assist in preparing Utilization Review Reports as necessary. • Coordinates and makes ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... · Assist in preparing Utilization Review Reports as necessary. · Coordinates and makes ...

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

$60 - $80/hr

... authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection ...

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

... authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection ...

UHS

UTILIZATION COORDINATOR

Danville, VA · On-site

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... review and respond to concerns expressed by customers. Together with the appropriate Department ...

Sentara Healthcare

Authorization Coordinator

Norfolk, VA · Remote

$18 - $22.25/hr

Talroo- Health, LPN, Acute Care, Managed Care, Authorization Coordinator, Clinical Review, Utilization Management, Diagnostic Imaging experience, Milliman Benefits: Caring For Your Family and Your ...

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Authorization Utilization Review information

What is authorization utilization review?

Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.

What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?

To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.

What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?

Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.

What is the difference between Authorization Utilization Review vs Claims Reviewer?

AspectAuthorization Utilization ReviewClaims Reviewer
CredentialsTypically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionalsOften requires similar credentials, focusing on insurance policies and claims processing
Work EnvironmentHospitals, insurance companies, healthcare facilitiesInsurance companies, third-party administrators, healthcare organizations
Industry UsageUsed to assess medical necessity before approving servicesUsed to evaluate claims for payment accuracy and compliance

Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.

What are popular job titles related to Authorization Utilization Review jobs in Virginia?

For Authorization Utilization Review jobs in Virginia, the most frequently searched job titles are:

What job categories do people searching Authorization Utilization Review jobs in Virginia look for?

The top searched job categories for Authorization Utilization Review jobs in Virginia are:

What cities in Virginia are hiring for Authorization Utilization Review jobs?

Cities in Virginia with the most Authorization Utilization Review job openings:

Authorization Utilization Review jobs near you
Infographic showing various Authorization Utilization Review job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 15% Part Time, 3% Contract, and 1% Nights. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution.

UTILIZATION REVIEW NURSE

Sentara Healthcare

Norfolk, VA • On-site, Remote

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 9 days ago

Sentara Health rating

6.8

Company rating: 6.8 out of 10

Based on 416 frontline employees who took The Breakroom Quiz

498th of 898 rated healthcare providers

Job description

City/State
Norfolk, VA
Work Shift
First (Days)
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
Keywords: Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQA
Benefits: Caring For Your Family and Your Career
• 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
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission "to improve health every day," this is a tobacco-free environment.
For positions that are available as remote work, Sentara Health employs associates in the following states:
Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

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