Remote RN Claims Reviewer - Utilization & Coding Expert

Sentara Health; West Virginia; Remote; USD 93,000 - 132,000; Full time

Benefits offered by this job

Medical benefits

Dental & Vision

401(k) with match

Paid time off

Tuition assistance

Debt payoff

Job summary

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for a remote, full-time position. Responsibilities include utilization management, pre/post payment claim reviews, and authorization assessments across inpatient and outpatient cases, with regulatory compliance involvement.

The ideal candidate holds a BSN, an RN license, and at least three years of acute care experience, plus experience in health plans or post-payment reviews is preferred.

Qualifications

• Bachelors Degree in Nursing (RN) is required.
• RN license (compact or Virginia) required.
• 3 years of acute care clinical experience required.
• Health Plan experience preferred.
• Claims or post payment reconsideration experience preferred.
• Medical Coding certification required within 1 year of hire.

Responsibilities

• Perform utilization management and claim reviews pre/post payment, including authorization review for inpatient/outpatient/retrospective cases.
• Address provider post-payment inquiries and reconsiderations; refer to Medical Directors as appropriate; ensure compliance with policy and regulatory standards.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem solving

Analytical skills

Education

Bachelor of Science in Nursing

Tools

MCG

Job description

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for a remote, full-time position. Responsibilities include utilization management, pre/post payment claim reviews, and authorization assessments across inpatient and outpatient cases, with regulatory compliance involvement.

The ideal candidate holds a BSN, an RN license, and at least three years of acute care experience, plus experience in health plans or post-payment reviews is preferred.