Remote RN: Clinical Claims Reviewer & Utilization

Sentara Health; Nevada; À distance; USD 93 000 - 132 000; Plein temps

Avantages offerts par ce poste

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off

Tuition Assistance

Résumé du poste

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote role. The RN will conduct utilization management and comprehensive claim reviews pre and post payment, including authorizations, across inpatient and outpatient cases.

Requirements include a BSN and RN license, with 3 years of acute care experience. The position is full-time with remote opportunities across many states, offering a competitive salary and robust benefits.

Qualifications

• Bachelors Degree in Nursing required.
• RN license required (Compact or Virginia).
• 3 years of acute care clinical experience required.
• Medical Coding certification required within 1 year of hire.

Responsabilités

• Perform utilization management and claim reviews pre/post payment, including authorization.
• Review provider post-payment inquiries and perform coding reviews for CMS/DMAS compliance.
• Ensure compliance with BOI, NCQA, CMS, DMAS and related guidelines.

Connaissances

Verbal communication

Written communication

Interpersonal skills

Problem solving

Facilitation

Analytical skills

Formation

Bachelor's Degree in Nursing

Outils

MCG

Description du poste

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote role. The RN will conduct utilization management and comprehensive claim reviews pre and post payment, including authorizations, across inpatient and outpatient cases.

Requirements include a BSN and RN license, with 3 years of acute care experience. The position is full-time with remote opportunities across many states, offering a competitive salary and robust benefits.