Remote RN Claims Reviewer — Utilization & Coding Expert

Sentara Health Administration, Inc.; Norfolk (VA); Remote; USD 93,000 - 132,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off

401k/403B with Employer Match

Tuition Assistance

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer, RN, for a full-time role with remote options across multiple states. You will perform utilization management, conduct pre- and post-payment claim reviews, and handle authorizations for inpatient and outpatient cases in line with plan policies and regulatory standards.

The candidate must have a BSN and RN license, with at least 3 years in acute care. CPC certification is preferred.

Qualifications

• RN Clinician with 3 years of acute care experience
• Experience in health plan utilization review or post-payment review is a plus
• Certification in Medical Coding (CPC) preferred within 1 year of hire

Responsibilities

• Perform utilization management services within licensure scope
• Conduct comprehensive pre- and post-payment claim reviews and authorization reviews
• Address provider post-payment inquiries and reconsiderations
• Ensure compliance with BOI, NCQA, CMS, and DMAS requirements
• Apply coding knowledge to promote accurate reimbursement and regulatory adherence

Skills

RN Clinician

Utilization management

Pre/post payment reviews

Regulatory compliance

Communication skills

Problem solving

Education

Bachelor's Degree in Nursing

Registered Nurse (RN) License

Certified Professional Coder (CPC) preferred

Tools

MCG guidelines

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer, RN, for a full-time role with remote options across multiple states. You will perform utilization management, conduct pre- and post-payment claim reviews, and handle authorizations for inpatient and outpatient cases in line with plan policies and regulatory standards.

The candidate must have a BSN and RN license, with at least 3 years in acute care. CPC certification is preferred.