Remote RN: Clinical Claims Reviewer & Utilization Review

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

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off

401k/403B with Employer Match

Tuition Assistance

Student Debt Pay Down

Job summary

Sentara Health Plans in Norfolk, VA is hiring a Clinical Claims Reviewer/RN for a remote role. The RN clinician will conduct utilization management, perform pre- and post-payment claim reviews, and handle authorization reviews across inpatient, outpatient, and concurrent cases.

Requirements include an RN with BSN and at least 3 years of acute care experience; CPC certification within 1 year of hire; strong written and verbal communication and analytical skills.

Qualifications

• 3 years of acute care clinical experience.
• RN BSN required.
• CPC certification within 1 year of hire.

Responsibilities

• Perform utilization management services within licensure scope; conduct comprehensive claim reviews pre and post payment and authorization review.
• Review provider post-payment inquiries and claim reconsiderations; ensure accurate coding per guidelines and policy; communicate review decisions to providers.

Skills

Acute care nursing experience

Utilization review

Post-payment review

Coding knowledge

Regulatory compliance

Communication skills

Education

Bachelor's Degree in Nursing

Job description

Sentara Health Plans in Norfolk, VA is hiring a Clinical Claims Reviewer/RN for a remote role. The RN clinician will conduct utilization management, perform pre- and post-payment claim reviews, and handle authorization reviews across inpatient, outpatient, and concurrent cases.

Requirements include an RN with BSN and at least 3 years of acute care experience; CPC certification within 1 year of hire; strong written and verbal communication and analytical skills.