Remote RN Claims Reviewer – Utilization & Review

Sentara Health; Maryland; 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

Student Debt Pay Down

Job summary

Sentara Health Plans is seeking an RN Clinician for a remote role focused on utilization management and claim review. The position requires an active RN license (VA or Compact) and a BSN, with at least 3 years of acute care experience, including utilization review or post-payment review.

CPC certification within 1 year is preferred. The role supports compliance with BOI/NCQA/CMS and requires strong communication and coding expertise.

Qualifications

• Bachelor's Degree in Nursing is required.
• RN license (Compact or Virginia) required.
• 3 years of acute care clinical experience required.
• Medical coding certification (CPC) within 1 year of hire.

Responsibilities

• Perform utilization management services including pre/post payment claim reviews and authorization reviews across inpatient, outpatient, and retrospective cases.
• Review provider post-payment inquiries and coding edits in accordance with CMS/NCQA/MCG guidelines and policies.

Skills

RN Clinician

BSN

Acute care

Utilization review

Medical Coding

Education

Bachelor's Degree in Nursing

Certified Professional Coder (CPC)

Job description

Sentara Health Plans is seeking an RN Clinician for a remote role focused on utilization management and claim review. The position requires an active RN license (VA or Compact) and a BSN, with at least 3 years of acute care experience, including utilization review or post-payment review.

CPC certification within 1 year is preferred. The role supports compliance with BOI/NCQA/CMS and requires strong communication and coding expertise.