Remote RN: Clinical Claims Reviewer & Utilization Expert

Sentara Health; Idaho; Remote; USD 67,000 - 111,000; Full time

Benefits offered by this job

Adoption, Fertility and Surrogacy Reim

Emergency Backup Care

Long-Term Disability/Short-Term Disab.

Life Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN for a remote role. The RN is responsible for utilization management, comprehensive claim reviews pre and post payment, and authorization reviews across inpatient, outpatient, concurrent, and retrospective cases.

Requires BSN, 3 years acute care experience, and coding/compliance proficiency. Remote opportunities are available across multiple states; base pay ranges from the low six figures annually with potential bonuses and shift

Qualifications

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

Responsibilities

• Perform utilization management services and comprehensive claim reviews (pre/post payment) and authorization reviews (inpatient, outpatient, concurrent, retrospective).
• Address provider post-payment inquiries and reconsiderations with correct coding per CMS and policy.
• Ensure compliance with health plan policy and regulatory standards (BOI, NCQA, CMS, DMAS).
• Apply coding guidelines to promote accurate reimbursement and maintain regulatory compliance.

Skills

Clinical judgment

Analytical thinking

Attention to detail

Communication

Education

Bachelor's Degree in Nursing

RN Licensure (Compact or Virginia)

Job description

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN for a remote role. The RN is responsible for utilization management, comprehensive claim reviews pre and post payment, and authorization reviews across inpatient, outpatient, concurrent, and retrospective cases.

Requires BSN, 3 years acute care experience, and coding/compliance proficiency. Remote opportunities are available across multiple states; base pay ranges from the low six figures annually with potential bonuses and shift