Remote RN: Claims Reviewer & Utilization Specialist

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

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off and Holidays

Paid Parental & Family Caregiver Leave

Student Debt Pay Down – $10,000

Education assistance

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote! This full-time position supports utilization management, pre/post payment reviews, and authorizations across various care settings.

The RN clinician must have a BSN and 3 years of acute care experience, with coding and regulatory knowledge. Remote options are available in many states, including Minnesota. Competitive benefits apply.

Qualifications

• Bachelor's degree in Nursing required.
• RN license (Compact or Virginia) required.
• 3 years of acute care clinical experience required.
• Medical Coding certification within 1 year of hire; CPC preferred.
• Utilization review and post-payment review experience a plus.
• Strong verbal, written and interpersonal communication; problem solving and analytic skills.

Responsibilities

• RN Clinician is responsible for performing utilization management services within the scope of licensure. Conducts comprehensive claim reviews pre and post payment and authorization review across inpatient, outpatient, concurrent and retrospective cases.
• Reviews provider post-payment inquiries and claim reconsiderations to ensure accurate coding and compliance with CMS, NCQA, and policy guidelines.

Skills

Utilization management

Post-payment review

Clinical coding

Regulatory compliance

Communication skills

Education

Bachelors Degree in Nursing

Tools

MCG guidelines

NCQA standards

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote! This full-time position supports utilization management, pre/post payment reviews, and authorizations across various care settings.

The RN clinician must have a BSN and 3 years of acute care experience, with coding and regulatory knowledge. Remote options are available in many states, including Minnesota. Competitive benefits apply.