Remote RN: Clinical Claims Reviewer & Utilization

Sentara Health; Florida; 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

Tuition Assistance

Job summary

Sentara Health Plans is seeking a Clinical Claims Reviewer, RN, remote, to support utilization management and post-payment review for a national footprint. The role requires RN with BSN and 3 years acute care experience, with coding knowledge and Coder certification within 1 year of hire.

Remote work options are available in multiple states including Florida. The successful candidate will conduct pre/post payment claim reviews, ensure compliance with NCQA, CMS, DMAS, and BOI guidelines, and

Qualifications

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

Responsibilities

• Perform utilization management services including onboard & post-payment claim reviews across inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations with appropriate referrals to Medical Directors; ensure compliance with BOI, NCQA, CMS, DMAS.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem solving

Analytic skills

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans is seeking a Clinical Claims Reviewer, RN, remote, to support utilization management and post-payment review for a national footprint. The role requires RN with BSN and 3 years acute care experience, with coding knowledge and Coder certification within 1 year of hire.

Remote work options are available in multiple states including Florida. The successful candidate will conduct pre/post payment claim reviews, ensure compliance with NCQA, CMS, DMAS, and BOI guidelines, and