Remote RN Claims Reviewer — Utilization & Appeals

Sentara Health; Wisconsin; A distancia; USD 93.000 - 132.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off

Descripción de la vacante

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for remote work with standard hours 8am-5pm EST. You will perform utilization management and comprehensive claim reviews pre- and post-payment, including authorization reviews across inpatient and outpatient cases.

The ideal candidate holds a BSN, an RN license (Compact or Virginia), and at least 3 years of acute care experience. A Medical Coding certification is required within 1 year of hire; MCG and NCQA knowledge are preferred.

Formación

• Bachelor's degree in Nursing required.
• RN license (Compact or Virginia) required.
• 3 years of acute care clinical experience required.
• Health Plan experience and claims/post-payment review experience preferred.
• Medical Coding certification required within 1 year of hire.
• MCG experience and NCQA knowledge preferred.

Responsabilidades

• Perform utilization management and claim reviews pre- and post-payment, including authorization review for inpatient and outpatient cases.
• Review provider post-payment inquiries and coding accuracy, including modifiers, code bundling, and CMS/NCQA guidelines.

Conocimientos

Utilization management

Regulatory compliance

Medical coding

Communication skills

Analytical skills

Educación

Bachelor's Degree in Nursing

Herramientas

Medical coding software

Descripción del empleo

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for remote work with standard hours 8am-5pm EST. You will perform utilization management and comprehensive claim reviews pre- and post-payment, including authorization reviews across inpatient and outpatient cases.

The ideal candidate holds a BSN, an RN license (Compact or Virginia), and at least 3 years of acute care experience. A Medical Coding certification is required within 1 year of hire; MCG and NCQA knowledge are preferred.