Remote RN Claims Reviewer — Utilization & Appeals

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

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off and Sick Leave

401k/403B with employer match

Tuition Assistance

Student Debt Pay Down

Parental and family care leave

Job summary

Sentara Health Plans in Norfolk, VA, is seeking a Clinical Claims Reviewer RN to work remotely in a full-time position. The role covers utilization management, pre/post payment claim reviews, and authorization assessments for inpatient and outpatient cases.

Ideal candidates hold a BSN with RN license (compact or VA) and at least 3 years of acute care experience, plus familiarity with NCQA, CMS, and DMAS guidelines. Remote nationwide opportunities and comprehensive benefits are offered.

Qualifications

• BSN and RN licensure required.
• 3 years of acute care clinical experience required.
• Experience with health plans, utilization review or post-payment review preferred.

Responsibilities

• Perform utilization management and pre/post payment claim reviews, including authorization reviews for inpatient, outpatient, concurrent and retrospective cases.
• Ensure compliance with BOI, NCQA, CMS, DMAS and plan policies; notify providers of review decisions and support accreditation efforts.

Skills

Utilization management

RN clinical experience

Medical coding knowledge

Education

Bachelor's Degree in Nursing

Tools

MCG knowledge

Job description

Sentara Health Plans in Norfolk, VA, is seeking a Clinical Claims Reviewer RN to work remotely in a full-time position. The role covers utilization management, pre/post payment claim reviews, and authorization assessments for inpatient and outpatient cases.

Ideal candidates hold a BSN with RN license (compact or VA) and at least 3 years of acute care experience, plus familiarity with NCQA, CMS, and DMAS guidelines. Remote nationwide opportunities and comprehensive benefits are offered.