Remote RN Claims Reviewer - Health Plan

Sentara Health; Indiana; Remote; USD 67,000 - 132,000; Full time

Benefits offered by this job

Adoption, Fertility and Surrogacy Reh

Emergency Backup Care

Long-Term Disability

Life Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer (RN) for a remote, full-time role. The RN will perform utilization management, pre/post payment reviews, and authorization assessments across inpatient, outpatient, concurrent, and retrospective cases.

Responsibilities include processing provider inquiries, ensuring compliance with policy and regulatory standards, and applying CMS/DMAS criteria to coding accuracy.

Qualifications

• RN Clinician must review utilization management and do pre/post payment and authorization reviews.
• 3 years of acute care clinical experience required.
• Medical Coding certification required within 1 year of hire.
• RN license (Compact or Virginia) required.

Responsibilities

• Perform comprehensive claim reviews pre and post payment and authorization reviews for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations; refer to Medical Directors as appropriate.
• Ensure compliance with health plan policy and regulatory standards (BOI, NCQA, CMS, DMAS).
• Apply CMS and DMAS criteria and coding guidelines to promote accurate reimbursement and appropriate coding.

Skills

RN Clinician

Policy compliance

Acute care experience

Medical coding familiarity

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer (RN) for a remote, full-time role. The RN will perform utilization management, pre/post payment reviews, and authorization assessments across inpatient, outpatient, concurrent, and retrospective cases.

Responsibilities include processing provider inquiries, ensuring compliance with policy and regulatory standards, and applying CMS/DMAS criteria to coding accuracy.