Remote RN - Clinical Claims & Utilization Reviewer

Sentara Health

Georgia

Remote

USD 93,000 - 132,000

Full time

4 days ago

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Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off

Parental Leave

401k/403B with Employer Match

Tuition Assistance

Student Debt Pay Down

Life Insurance

Disability Insurance

Bonus opportunities

Job summary

Sentara Health Plans is seeking a Clinical Claims Reviewer/RN for a remote role. This full-time, 40-hour position offers remote work across multiple states and requires RN licensure, BSN, and CPC certification within a year. The role focuses on utilization management, claim reviews, and compliance with CMS/NCQA/DMAS guidelines.

The ideal candidate has 3 years of acute care experience, health plan familiarity, and strong analytical skills to support accurate reimbursement and regulatory adherence.

Qualifications

3 years of acute care clinical experience required.
Health Plan experience preferred.
Claims or post payment reconsideration experience preferred.
Medical Coding certification required within 1 year of hire.

Responsibilities

Perform utilization management and claim reviews pre/post payment, including authorization reviews.
Ensure compliance with BOI/NCQA/CMS/DMAS requirements and produce provider notifications.

Skills

Utilization management

Claim reviews

Regulatory compliance

Clinical coding awareness

Communication skills

Education

Bachelor of Science in Nursing

RN License (VA or Compact)

CPC Certification

Tools

MCG experience

Health Plan coding policies

Job description

The ideal candidate has 3 years of acute care experience, health plan familiarity, and strong analytical skills to support accurate reimbursement and regulatory adherence.

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