Clinical Claims Reviewer/ RN

Sentara Healthcare Inc; Norfolk (VA); Hybrid; USD 67,000 - 111,000; Full time

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote, full-time role. The position supports utilization management and conducts comprehensive pre- and post-payment claim reviews across inpatient and outpatient settings, with provider inquiries and appeals handling.

Required: BSN, RN license (compact or VA), 3 years acute care experience; CPC preferred. Sentara offers competitive compensation and remote work opportunities across multiple states.

Qualifications

• 3 years of acute care clinical experience required.
• Health Plan experience preferred.
• Claims or post payment reconsideration experience preferred.
• RN BSN required.
• Certification: CPC preferred.

Responsibilities

• Perform utilization management and claim reviews pre- and post-payment for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations; ensure coding accuracy per CMS/NCQA guidelines and DMAS/MCG criteria.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem solving

Analytical skills

Education

Bachelor's degree in Nursing

Job description

Sentara Health Plansis 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 - 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!

Talroo - Nursing

Sentara is currently reviewing market compensation for this role. Our Talent Acquisition team will be able to share more specific information during the recruiting process.

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