Remote RN Claims Reviewer - Utilization & Appeals

Sentara Health; Ohio; 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

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote position. You will perform utilization management, conduct pre/post payment claim reviews, and authorization review across inpatient, outpatient, and retrospective cases.

The role requires an RN license (compact or VA), a BSN, and at least 3 years of acute care experience. This remote role supports multiple states and offers comprehensive benefits and a competitive salary.

Qualifications

• RN BSN required and 3 years of acute care clinical experience.
• Experience with utilization review and post-payment review preferred.
• Knowledge of NCQA, CMS, and regulatory standards is beneficial.

Responsibilities

• Perform utilization management and claim reviews pre- and post payment across inpatient and outpatient cases.
• Provide provider inquiries support and coordinate with Medical Directors as needed.

Skills

Clinical claims review

Utilization management

Communication skills

Analytic skills

Education

Bachelor of Science in Nursing

RN License (Compact or Virginia)

Tools

MCG

CMS guidelines

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote position. You will perform utilization management, conduct pre/post payment claim reviews, and authorization review across inpatient, outpatient, and retrospective cases.

The role requires an RN license (compact or VA), a BSN, and at least 3 years of acute care experience. This remote role supports multiple states and offers comprehensive benefits and a competitive salary.