Clinical Claims Reviewer, RN

Job not on LinkedIn

🔥 8 hours ago

🏈 Alabama, Florida, +24 more states – Remote

🏈 Alabama – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote ❄️ Minnesota – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $93.3k - $132.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Sentara Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1890

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Sentara Health is a leading healthcare system that operates over 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals. The company is dedicated to providing exceptional patient care, fostering professional development, and maintaining a diverse workforce. Sentara Health aims to improve health every day and has been recognized for its clinical and operational performance, being named one of the top 15 health systems by IBM Watson Health. The organization supports its employees in achieving their full potential and encourages growth and innovation in the healthcare sector.

📋 Description

• Perform utilization management services within the scope of licensure • Conduct comprehensive pre- and post-payment claim reviews • Review inpatient, outpatient, concurrent, and retrospective authorization cases • Address provider post-payment inquiries and reconsiderations • Refer cases to Medical Directors as appropriate • Ensure compliance with health plan policies and regulatory requirements, including BOI, NCQA, CMS, and Virginia DMAS • Review member eligibility and benefits, medical policy, vendor guidelines, MCG, DMAS, and CMS criteria • Provide written notification of review decisions to providers • Facilitate accreditation by interpreting and applying accrediting and regulatory standards • Review claim reconsiderations for accurate coding • Evaluate code selection, modifiers, code bundling, unlisted codes, excessive procedures, diagnosis compatibility, frequency limits, and other coding edits • Apply clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement

🎯 Requirements

• RN BSN required • Bachelor's Degree in Nursing required • Registered Nurse (RN) License (Compact or Virginia) required • 3 years of acute care clinical experience required • Medical Coding certification required within 1 year of hire • Previous Utilization Review and Post Payment Review a plus • MCG experience preferred • Knowledge of NCQA preferred • Strong verbal, written and interpersonal communication skills • Problem solving skills • Facilitation skills • Analytic skills • Certified Professional Coder (CPC) preferred • Health Plan experience preferred • Claims or post payment reconsideration experience preferred • Standard working hours availability: 8am to 5pm EST, Monday-Friday • Remote work available in Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, or Wyoming

🏖️ Benefits

• Medical, Dental, Vision plans • Adoption, Fertility and Surrogacy Reimbursement up to $10,000 • Paid Time Off and Sick Leave • Paid Parental & Family Caregiver Leave • Emergency Backup Care • Long-Term, Short-Term Disability, and Critical Illness plans • Life Insurance • 401k/403B with Employer Match • Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education • Student Debt Pay Down – $10,000 • Pet Insurance • Legal Resources Plan • Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met • Market-competitive compensation packages, including incentives and benefits • Family-friendly culture with community involvement and development and growth opportunities • Tobacco-free environment