Remote RN Claims Reviewer - Utilization & Post-Payment

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

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Paid Time Off

Parental Leave

Disability Insurance

Life Insurance

401k with Employer Match

Tuition Assistance

Student Debt Pay Down

Pet Insurance

Job summary

Sentara Health Plans is seeking a Clinical Claims Reviewer RN for a remote, full-time position (40 hours/week). The role centers on utilization management, including pre/post payment claim reviews and authorization oversight for inpatient and outpatient settings.

The ideal candidate holds a BSN, has at least 3 years of acute care experience, and understands coding guidelines. NCQA and CMS knowledge is preferred; a Medical Coding certification must be obtained within 1 year of hire.

Qualifications

• RN BSN is required.
• Minimum 3 years of acute care clinical experience is required.
• Health Plan experience is preferred.
• Prior claims or post-payment review experience is preferred.
• Medical Coding certification required within 1 year of hire.

Responsibilities

• Perform utilization management services within licensure. Conduct comprehensive claim reviews pre and post payment, and authorization review for inpatient/outpatient/concurrent/retrospective cases.
• Address post-payment inquiries and reconsiderations; refer to Medical Directors as appropriate. Ensure compliance with policy and regulatory requirements.

Skills

RN

BSN

Acute care

Utilization Review

NCQA knowledge

Communication skills

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans is seeking a Clinical Claims Reviewer RN for a remote, full-time position (40 hours/week). The role centers on utilization management, including pre/post payment claim reviews and authorization oversight for inpatient and outpatient settings.

The ideal candidate holds a BSN, has at least 3 years of acute care experience, and understands coding guidelines. NCQA and CMS knowledge is preferred; a Medical Coding certification must be obtained within 1 year of hire.