Remote RN: Claims & Utilization Review Specialist

Sentara Health; New Hampshire; Remote; USD 93.000 - 132.000; Vollzeit

Benefits dieser Stelle

Medical, Dental, Vision plans

401k/403B with employer match

Tuition Assistance

Zusammenfassung

Sentara Health Plans is hiring a Clinical Claims Reviewer RN for a remote role. The position is full-time, 40 hours, with standard hours 8am–5pm EST, Monday to Friday. Remote opportunities are available across many states, including New Hampshire, with licensure in Virginia or compact licensure.

A CPC is preferred and RN licensure is required. Responsibilities include utilization management, pre/post payment review, and ensuring compliance with CMS, NCQA, DMAS, and BOI standards.

Qualifikationen

• 3 years of acute care clinical experience
• RN licensure with compact or VA
• Medical coding certification within 1 year of hire

Aufgaben

• Perform utilization management reviews pre and post payment for inpatient, outpatient, concurrent and retrospective cases.
• Review provider post-payment inquiries and reconsiderations; ensure compliant coding and editorial accuracy.

Kenntnisse

Utilization management

Post-payment review

Coding knowledge

NCQA/CMS awareness

Ausbildung

Bachelors Degree in Nursing

Jobbeschreibung

Sentara Health Plans is hiring a Clinical Claims Reviewer RN for a remote role. The position is full-time, 40 hours, with standard hours 8am–5pm EST, Monday to Friday. Remote opportunities are available across many states, including New Hampshire, with licensure in Virginia or compact licensure.

A CPC is preferred and RN licensure is required. Responsibilities include utilization management, pre/post payment review, and ensuring compliance with CMS, NCQA, DMAS, and BOI standards.