Remote RN Claims Reviewer — Utilization & Post-Payment

Sentara Health Plans; Norfolk (VA); Hybrid; USD 93,000 - 132,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k with employer match

Tuition Assistance

Paid Time Off & Leave

Job summary

Sentara Health Plans is seeking an RN Clinician for remote utilization management and claims review. You will perform pre/post payment reviews, authorizations, and post-payment inquiries in a compliant manner with NCQA, CMS, DMAS guidelines.

Requires a BSN and 3 years of acute care clinical experience; CPC preferred. Remote options available across multiple states, with standard 8am-5pm EST hours, M-F.

Qualifications

• Active RN license (Compact or VA)
• Minimum 3 years of acute care clinical experience
• Experience in utilization review or post-payment review is a plus
• CPC certification preferred or to be obtained within 1 year

Responsibilities

• Perform utilization management and claim reviews (pre and post payment)
• Conduct authorization reviews for inpatient, outpatient, concurrent and retrospective cases
• Address provider post-payment inquiries and reconsiderations
• Ensure compliance with BOI, NCQA, CMS, DMAS and other regulations
• Apply CMS and coding guidelines to promote accurate coding and reimbursement

Skills

RN Licensure

Acute care experience

Communication skills

Education

BSN or higher in Nursing

Tools

Medical coding knowledge

Job description

Sentara Health Plans is seeking an RN Clinician for remote utilization management and claims review. You will perform pre/post payment reviews, authorizations, and post-payment inquiries in a compliant manner with NCQA, CMS, DMAS guidelines.

Requires a BSN and 3 years of acute care clinical experience; CPC preferred. Remote options available across multiple states, with standard 8am-5pm EST hours, M-F.