Remote RN: Claims Review & Utilization Expert

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401k/403B with employer match

Paid time off

Tuition assistance

Student debt payoff

Parental leave

Job summary

Sentara Health Plans is seeking an experienced RN Clinician for a remote role to perform comprehensive claim reviews, pre- and post-payment, and authorization reviews across inpatient and outpatient settings. You will handle provider inquiries and ensure adherence to policy and regulatory standards while supporting accreditation efforts.

The position requires an RN with a BSN, 3 years of acute care experience, and a CPC certification within 1 year.

Qualifications

• RN BSN required with active license.
• 3 years acute care clinical experience required.
• Medical coding certification within 1 year of hire.

Responsibilities

• Perform utilization management with pre/post payment claim reviews and authorization review for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations, including referrals to Medical Directors.
• Ensure compliance with health plan policy and regulatory standards (BOI, NCQA, CMS, DMAS).

Skills

Acute care experience

Utilization review

Post-payment review

Coding knowledge

Regulatory knowledge

Education

Bachelors Degree in Nursing

RN License

CPC certification

Tools

MCG experience

NCQA knowledge

CMS guidelines

Job description

Sentara Health Plans is seeking an experienced RN Clinician for a remote role to perform comprehensive claim reviews, pre- and post-payment, and authorization reviews across inpatient and outpatient settings. You will handle provider inquiries and ensure adherence to policy and regulatory standards while supporting accreditation efforts.

The position requires an RN with a BSN, 3 years of acute care experience, and a CPC certification within 1 year.