Remote RN Claims Reviewer: Utilization & Coding

Sentara Health; Maine; Remoto; USD 93.000 - 132.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical, Dental, Vision plans

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

401k/403B with Employer Match

Descrizione del lavoro

Sentara Health Plans is seeking a Clinical Claims Reviewer RN for a remote role. The RN with BSN will perform utilization management, review pre- and post-payment claims, authorize inpatient/outpatient cases, and liaise with Medical Directors as needed.

You will ensure compliance with plan policies and regulatory standards (NCQA, CMS, DMAS) and participate in post-payment reviews, coding accuracy, and appeals. Full-time, 40 hours/week, EST 8-5.

Competenze

• RN with BSN license required.
• 3 years of acute care clinical experience.
• Experience in utilization review and post-payment review preferred.
• Medical Coding certification required within 1 year of hire.

Mansioni

• Perform utilization management by reviewing pre- and post-payment claims and authorizations across inpatient, outpatient, concurrent, and retrospective cases.
• Review provider post-payment inquiries and claim reconsiderations, ensuring correct coding and compliance with CMS/NCQA/MCG guidelines and health plan policies.

Conoscenze

Utilization management

Medical coding

Analytical skills

Verbal communication

Interpersonal skills

Formazione

Bachelor's Degree in Nursing

Strumenti

MCG guidelines

Descrizione del lavoro

Sentara Health Plans is seeking a Clinical Claims Reviewer RN for a remote role. The RN with BSN will perform utilization management, review pre- and post-payment claims, authorize inpatient/outpatient cases, and liaise with Medical Directors as needed.

You will ensure compliance with plan policies and regulatory standards (NCQA, CMS, DMAS) and participate in post-payment reviews, coding accuracy, and appeals. Full-time, 40 hours/week, EST 8-5.