Clinical Claims Reviewer/ RN

Sentara Health Plans; Norfolk (VA); Hybrid; USD 93,000 - 132,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k with employer match

Tuition Assistance

Paid Time Off & Leave

Job summary

Sentara Health Plans is seeking an RN Clinician for remote utilization management and claims review. You will perform pre/post payment reviews, authorizations, and post-payment inquiries in a compliant manner with NCQA, CMS, DMAS guidelines.

Requires a BSN and 3 years of acute care clinical experience; CPC preferred. Remote options available across multiple states, with standard 8am-5pm EST hours, M-F.

Qualifications

• Active RN license (Compact or VA)
• Minimum 3 years of acute care clinical experience
• Experience in utilization review or post-payment review is a plus
• CPC certification preferred or to be obtained within 1 year

Responsibilities

• Perform utilization management and claim reviews (pre and post payment)
• Conduct authorization reviews for inpatient, outpatient, concurrent and retrospective cases
• Address provider post-payment inquiries and reconsiderations
• Ensure compliance with BOI, NCQA, CMS, DMAS and other regulations
• Apply CMS and coding guidelines to promote accurate coding and reimbursement

Skills

RN Licensure

Acute care experience

Communication skills

Education

BSN or higher in Nursing

Tools

Medical coding knowledge

Job description

# ***Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote!*****Status: Full-time, permanent position (40 hours)****Standard working hours: 8am to 5pm EST, M-F.****Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming****Job responsibilities:*** RN Clinician is responsible for performing utilization management services within the scope of licensure. Primary responsibilities include conducting comprehensive claim reviews both pre and post payment as well as authorization review covering inpatient, outpatient, concurrent and retrospective cases. This role also addresses provider post-payment inquiries and reconsiderations including referrals to Medical Directors as appropriate. Ensures compliance with health plan policy and other regulatory agencies such as Bureau of Insurance (BOI), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Virginia Department of Medical Assistance Services (DMAS). Reviews are based on member eligibility and benefits, health plan medical policy, vendor specific guidelines and policies, MCG, DMAS and CMS criterion according to the member’s plan. Responsible for written notification of review decision to providers (LOB specific). Facilitates accreditation by knowing, understanding, correctly interpreting and accurately applying accrediting and regulatory requirements and standards.* RN Clinician is responsible for reviewing provider post-payment inquiries and claim reconsiderations to ensure accurate coding in accordance with established coding guidelines, CMS guidelines, Health Plan Coding Payment Policy, and Claim Payment Policy. This includes evaluating correct code selection, appropriate use of modifiers, code bundling, unlisted codes, excessive procedures of the same type, procedures incompatible with the diagnosis, maximum frequency exceeded, and other coding edits. RN Clinician applies clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement. RN BSN Required. Must possess 3 years of acute care clinical experience. Previous Utilization Review and Post Payment Review a plus. MCG experience preferred. Knowledge of NCQA Preferred. Requires strong verbal, written and interpersonal communication skills, problem solving skills, facilitation skills and analytic skills. Medical Coding certification required within 1 year of hire.**Education:*** Bachelors Degree in Nursing **REQUIRED****Certification/Licensure*** Registered Nurse (RN) License (Compact or Virginia) **REQUIRED*** Certified Professional Coder (CPC) **preferred****Experience:*** 3 years of acute care clinical experience **REQUIRED*** Health Plan experience **preferred*** Claims or post payment reconsideration experience is **preferred****Sentara Health Plans** provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees.Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.*We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $66,830.4 – $111,384. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities**Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.***Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!****To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-105056**Talroo - NursingClinical Claims Reviewer, Appeals, Denials, Utilization management, Registered Nurse, BSN, ADN, Nursing, Managed Care, MCO, Health Plan, Virginia, RN, VA, North Carolina, 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 (state), West Virginia, Wisconsin, WyomingWe provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $93,350.40 - $132,433.60 annually.Additional compensation may be available for this role, such as shift differentials, standby/on-call pay, overtime, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually. **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.