Clinical Claims Reviewer/ RN

Sentara Health; Utah; Remote; USD 93,000 - 132,000; Full time

Benefits offered by this job

Medical, dental, vision

Paid time off

401k/retirement plan

Life and disability insurance

Education assistance

Student debt payoff

Flexible work options

Job summary

Sentara Health Plans in Norfolk, VA seeks a Clinical Claims Reviewer/RN for a remote-friendly, full-time role. You will conduct comprehensive pre- and post-payment claim reviews, including authorization reviews across inpatient and outpatient cases, while ensuring compliance with policies and regulatory standards.

The ideal candidate holds a BSN, 3 years of acute care experience, and a coders' background with NCQA/MCG familiarity.

Qualifications

• RN licensure in Virginia or compact state.
• Certified Professional Coder (CPC) preferred.
• 3 years of acute care clinical experience required.

Responsibilities

• Perform utilization management with pre- and post-payment claim reviews and authorization reviews for inpatient/outpatient cases.
• Ensure accurate coding and apply CMS/MCG guidelines; respond to post-payment inquiries and provider reconsiderations.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem solving

Analytical thinking

Education

Bachelor’s Degree in Nursing

Job description

City/State Norfolk, VA

First (Days)

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.

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.

Clinical 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, Wyoming

We 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, on‑call pay, 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. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.

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.