Clinical Claims Reviewer/ RN

Sentara Health•Virginia Remote, VA

7d•$93,350 - $132,434•Remote

About The Position

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN. This is a full-time, permanent position with standard working hours of 8am to 5pm EST, Monday through Friday. Remote opportunities are available in multiple states. The RN Clinician is responsible for performing utilization management services within the scope of licensure, including comprehensive claim reviews (pre and post payment) and authorization reviews for various case types. This role also handles provider post-payment inquiries and reconsiderations, ensuring compliance with health plan policies and regulatory agencies like BOI, NCQA, CMS, and DMAS. Reviews are based on member eligibility, benefits, medical policy, and specific guidelines. The position requires written notification of review decisions to providers and facilitates accreditation by applying regulatory requirements. Additionally, the RN Clinician reviews provider post-payment inquiries and claim reconsiderations for accurate coding in accordance with established guidelines, evaluating code selection, modifiers, bundling, and other coding edits. Clinical knowledge and coding expertise are applied to promote compliance, accuracy, and appropriate reimbursement.

Requirements

Registered Nurse (RN) License (Compact or Virginia) REQUIRED
Bachelors Degree in Nursing REQUIRED
3 years of acute care clinical experience REQUIRED
Medical Coding certification required within 1 year of hire.
Strong verbal, written and interpersonal communication skills.
Problem solving skills.
Facilitation skills.
Analytic skills.

Nice To Haves

Previous Utilization Review and Post Payment Review a plus.
MCG experience preferred.
Knowledge of NCQA Preferred.
Health Plan experience preferred.
Claims or post payment reconsideration experience is preferred.
Certified Professional Coder (CPC) preferred.

Responsibilities

Performing utilization management services within the scope of licensure.
Conducting comprehensive claim reviews both pre and post payment.
Conducting authorization reviews covering inpatient, outpatient, concurrent and retrospective cases.
Addressing provider post-payment inquiries and reconsiderations.
Ensuring compliance with health plan policy and regulatory agencies (BOI, NCQA, CMS, DMAS).
Reviewing based on member eligibility and benefits, health plan medical policy, vendor specific guidelines and policies, MCG, DMAS and CMS criterion according to the member’s plan.
Providing written notification of review decision to providers (LOB specific).
Facilitating accreditation by knowing, understanding, correctly interpreting and accurately applying accrediting and regulatory requirements and standards.
Reviewing provider post-payment inquiries and claim reconsiderations to ensure accurate coding in accordance with established coding guidelines, CMS guidelines, Health Plan Coding Payment Policy, and Claim Payment Policy.
Evaluating correct code selection, appropriate use of modifiers, code bundling, unlisted codes, excessive procedures of the same type, procedures incompatible with the diagnosis, maximum frequency exceeded, and other coding edits.
Applying clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement.

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.