Remote RN – Claims Reviewer & Utilization Review

Sentara Health; Tallahassee (FL); Remote; USD 67,000 - 132,000; Full time

Benefits offered by this job

Comprehensive benefits package

Remote work options

Performance-based bonus opportunities

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN. The role focuses on utilization management, pre/post payment claim reviews, and authorization assessments for various care settings.

Remote work options are available, with a background in acute care nursing and coding required. The successful candidate will ensure compliance with state and federal guidelines, including CMS and NCQA, and will handle post-payment inquiries and potential reconsiderations.

Qualifications

• RN Clinician conducts utilization management and claim reviews.
• Ability to review pre/post payment denials and authorizations.
• Keeps compliance with BOI, NCQA, CMS, DMAS and policy standards.
• 3 years of acute care clinical experience required; BSN preferred.

Responsibilities

• Review provider post-payment inquiries and reconsiderations for accurate coding.
• Evaluate correct code selection, modifiers, bundling and CMS guidelines.
• Ensure coding aligns with established guidelines and policies.

Skills

RN license

Acute care experience

Medical coding knowledge

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN. The role focuses on utilization management, pre/post payment claim reviews, and authorization assessments for various care settings.

Remote work options are available, with a background in acute care nursing and coding required. The successful candidate will ensure compliance with state and federal guidelines, including CMS and NCQA, and will handle post-payment inquiries and potential reconsiderations.