Remote RN: Clinical Claims Reviewer & Coding Expert

Sentara Health; Austin (TX); Remote; USD 67,000 - 132,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Bonus opportunities

Remote work options

Job summary

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for a remote role. You will perform utilization management, comprehensive pre/post-payment claim reviews, and authorization assessments across inpatient, outpatient, and retrospective cases.

The role requires an RN with a BSN and an active license, plus at least 3 years of acute care experience and Medical Coding certification within 12 months of hire. Remote opportunities and competitive benefits are offered.

Qualifications

• RN with BSN and active license, compact or VA.
• Minimum 3 years acute care clinical experience.
• Medical Coding certification within 1 year of hire.
• Health plan experience preferred.
• Claims or post-payment reconsideration experience preferred.

Responsibilities

• Perform utilization management services within licensure scope.
• Conduct comprehensive claim reviews pre- and post-payment and authorization reviews for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations with appropriate referrals to Medical Directors.
• Ensure compliance with health plan policy and regulatory agencies (BOI, NCQA, CMS, DMAS).
• Review coding to ensure accuracy per CMS, policy, and coding guidelines.

Skills

Acute care experience

RN Licensure

BSN

Medical Coding

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for a remote role. You will perform utilization management, comprehensive pre/post-payment claim reviews, and authorization assessments across inpatient, outpatient, and retrospective cases.

The role requires an RN with a BSN and an active license, plus at least 3 years of acute care experience and Medical Coding certification within 12 months of hire. Remote opportunities and competitive benefits are offered.