Remote RN Clinical Claims Reviewer – Utilization & Appeals

Sentara Healthcare Inc; Norfolk (VA); Hybrid; USD 67,000 - 111,000; Full time

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote, full-time role. The position supports utilization management and conducts comprehensive pre- and post-payment claim reviews across inpatient and outpatient settings, with provider inquiries and appeals handling.

Required: BSN, RN license (compact or VA), 3 years acute care experience; CPC preferred. Sentara offers competitive compensation and remote work opportunities across multiple states.

Qualifications

• 3 years of acute care clinical experience required.
• Health Plan experience preferred.
• Claims or post payment reconsideration experience preferred.
• RN BSN required.
• Certification: CPC preferred.

Responsibilities

• Perform utilization management and claim reviews pre- and post-payment for inpatient, outpatient, concurrent and retrospective cases.
• Address provider post-payment inquiries and reconsiderations; ensure coding accuracy per CMS/NCQA guidelines and DMAS/MCG criteria.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem solving

Analytical skills

Education

Bachelor's degree in Nursing

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/RN for a remote, full-time role. The position supports utilization management and conducts comprehensive pre- and post-payment claim reviews across inpatient and outpatient settings, with provider inquiries and appeals handling.

Required: BSN, RN license (compact or VA), 3 years acute care experience; CPC preferred. Sentara offers competitive compensation and remote work opportunities across multiple states.