Clinical Claims Reviewer/ RN

Sentara Health; Tallahassee (FL); Remote; USD 67.000 - 132.000; Vollzeit

Benefits dieser Stelle

Comprehensive benefits package

Remote work options

Performance-based bonus opportunities

Zusammenfassung

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN. The role focuses on utilization management, pre/post payment claim reviews, and authorization assessments for various care settings.

Remote work options are available, with a background in acute care nursing and coding required. The successful candidate will ensure compliance with state and federal guidelines, including CMS and NCQA, and will handle post-payment inquiries and potential reconsiderations.

Qualifikationen

• RN Clinician conducts utilization management and claim reviews.
• Ability to review pre/post payment denials and authorizations.
• Keeps compliance with BOI, NCQA, CMS, DMAS and policy standards.
• 3 years of acute care clinical experience required; BSN preferred.

Aufgaben

• Review provider post-payment inquiries and reconsiderations for accurate coding.
• Evaluate correct code selection, modifiers, bundling and CMS guidelines.
• Ensure coding aligns with established guidelines and policies.

Kenntnisse

RN license

Acute care experience

Medical coding knowledge

Ausbildung

Bachelor's Degree in Nursing

Jobbeschreibung

City/State

Norfolk, VA

Work Shift: Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote!

Status: Full-time, permanent position (40 hours)

Remote opportunities available in the following states:

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. 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. Medical Coding certification required within 1 year of hire.

Bachelors Degree in Nursing

REQUIRED

Registered Nurse (RN) License (Compact or Virginia)

REQUIRED

3 years of acute care clinical experience

REQUIRED

~ Health Plan experience

preferred

~ Claims or post payment reconsideration experience is

preferred

Sentara Health Plans

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.

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!

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, shift premiums, extra-shift incentives, or bonus opportunities. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.

Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; paid time off (vacation, sick time, and holidays); Medical, Dental, Vision plans

• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life 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: