Remote RN Claims Reviewer — Utilization & Denials Expert

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

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote role, with a 40-hour workweek and EST hours. The position requires RN licensure (compact or VA), a BSN, and at least 3 years of acute care experience, with CPC preferred. Remote opportunities span many states including PA.

Responsibilities include utilization management, detailed claim reviews, coding accuracy, and regulatory compliance with NCQA, CMS, DMAS, and BOI standards. Competitive benefits provided.

Qualifications

• RN with BSN is required.
• 3 years of acute care clinical experience is required.
• Medical Coding certification (CPC) required within 1 year of hire.

Responsibilities

• Perform utilization management services and conduct pre/post payment claim reviews across inpatient, outpatient, concurrent and retrospective cases.
• Review provider post-payment inquiries and claim reconsiderations, ensuring accurate coding and adherence to CMS, NCQA, DMAS, and other guidelines.

Skills

Utilization management

Claims review

Post-payment review

Medical coding

Education

Bachelor's degree in Nursing

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote role, with a 40-hour workweek and EST hours. The position requires RN licensure (compact or VA), a BSN, and at least 3 years of acute care experience, with CPC preferred. Remote opportunities span many states including PA.

Responsibilities include utilization management, detailed claim reviews, coding accuracy, and regulatory compliance with NCQA, CMS, DMAS, and BOI standards. Competitive benefits provided.