Remote RN Clinical Claims Reviewer | Utilization Management

Sentara Health; Louisiana; 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

Job summary

Sentara Health Plans in Norfolk, VA, is seeking a Clinical Claims Reviewer/RN for a remote role. You will perform utilization management and pre/post-payment claim reviews across inpatient and outpatient cases, ensuring compliance with CMS, NCQA, DMAS, and health plan policies.

This full-time position offers remote work nationwide across listed states, with standard hours 8am–5pm EST, M-F, and a comprehensive benefits package.

Qualifications

• RN Clinician with BSN and active RN license (Compact or VA).
• 3 years of acute care clinical experience required.
• Medical Coding certification required within 1 year of hire.

Responsibilities

• Conduct utilization management and claim reviews pre- and post-payment across inpatient, outpatient, and concurrent/retrospective cases in accordance with policy and regulatory standards (BOI, NCQA, CMS, DMAS).
• Review provider post-payment inquiries and reconsiderations; ensure accurate coding per CMS guidelines and policy; communicate decisions to providers.

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans in Norfolk, VA, is seeking a Clinical Claims Reviewer/RN for a remote role. You will perform utilization management and pre/post-payment claim reviews across inpatient and outpatient cases, ensuring compliance with CMS, NCQA, DMAS, and health plan policies.

This full-time position offers remote work nationwide across listed states, with standard hours 8am–5pm EST, M-F, and a comprehensive benefits package.