Remote RN: Clinical Claims Reviewer & Utilization

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

Job summary

Sentara Health Plans in Norfolk, VA is seeking a Clinical Claims Reviewer/RN for a remote-friendly, full-time role. The RN Clinician handles utilization management, pre- and post-payment claim reviews, and authorization reviews across inpatient and outpatient cases.

Candidates must be a BSN, hold an RN license (Virginia or compact), and have at least 3 years of acute care experience; knowledge of coding and CMS/DMAS guidelines is desirable.

Qualifications

• RN license required (Compact or Virginia).
• 3 years of acute care clinical experience required.
• Medical coding knowledge or experience preferred.

Responsibilities

• Perform utilization management reviews and claim reviews (pre/post payment).
• Conduct authorization reviews for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations, ensure compliance with policy and regulations.

Education

Bachelor's Degree in Nursing

RN License

Job description

Sentara Health Plans in Norfolk, VA is seeking a Clinical Claims Reviewer/RN for a remote-friendly, full-time role. The RN Clinician handles utilization management, pre- and post-payment claim reviews, and authorization reviews across inpatient and outpatient cases.

Candidates must be a BSN, hold an RN license (Virginia or compact), and have at least 3 years of acute care experience; knowledge of coding and CMS/DMAS guidelines is desirable.