Remote RN Claims Reviewer: Utilization & Appeals

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

Benefits offered by this job

Adoption, Fertility and Surrogacy Reim

Emergency Backup Care

Disability plans

Life Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plans seeks a Clinical Claims Reviewer RN for remote work. You will perform utilization management, review pre/post payment claims and authorizations for inpatient/outpatient cases, and address provider inquiries with appropriate referrals to Medical Directors.

Requirements include a BSN, an RN license, and 3 years of acute care experience. The role supports multiple states and offers full-time employment with competitive pay and benefits.

Qualifications

• RN licensure required in participating states.
• BSN preferred or required by role.
• Experience with medical coding guidelines and CMS rules.

Responsibilities

• Perform utilization management and comprehensive claim reviews pre and post payment.
• Conduct authorization reviews for inpatient, outpatient, concurrent and retrospective cases.
• Address provider inquiries and reconsiderations with appropriate referrals when needed.
• Ensure compliance with BOI, NCQA, CMS, DMAS and plan policies.

Skills

Acute care experience

Regulatory compliance

Coding knowledge

Remote work

Education

Bachelor's Degree in Nursing

Registered Nurse License

Job description

Sentara Health Plans seeks a Clinical Claims Reviewer RN for remote work. You will perform utilization management, review pre/post payment claims and authorizations for inpatient/outpatient cases, and address provider inquiries with appropriate referrals to Medical Directors.

Requirements include a BSN, an RN license, and 3 years of acute care experience. The role supports multiple states and offers full-time employment with competitive pay and benefits.