Clinical Claims Reviewer/ RN
Sentara Health Plans is hiring a Clinical Claims Reviewer/RN - Remote. This is a full-time, permanent position (40 hours), with standard working hours of 8am to 5pm EST, M-F. Remote opportunities are available in select states.
About the Role
RN Clinician is responsible for performing utilization management services within the scope of licensure. Primary responsibilities include conducting comprehensive claim reviews both pre and post payment as well as authorization review covering inpatient, outpatient, concurrent and retrospective cases. This role also addresses provider post-payment inquiries and reconsiderations including referrals to Medical Directors as appropriate.
Responsibilities
- Perform utilization management services within the scope of licensure
- Conduct comprehensive claim reviews both pre and post payment
- Perform authorization review covering inpatient, outpatient, concurrent and retrospective cases
- Address provider post-payment inquiries and reconsiderations, including referrals to Medical Directors as appropriate
- Ensure compliance with health plan policy and other regulatory agencies such as Bureau of Insurance (BOI), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Virginia Department of Medical Assistance Services (DMAS)
- Base reviews 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
- Responsible for written notification of review decision to providers (LOB specific)
- Facilitate accreditation by knowing, understanding, correctly interpreting and accurately applying accrediting and regulatory requirements and standards
- Review 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
- Evaluate 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
- Apply clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement
Requirements
- RN BSN Required
- Bachelors 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
- Requires strong verbal, written and interpersonal communication skills, problem solving skills, facilitation skills and analytic skills
Qualifications
- Previous Utilization Review and Post Payment Review a plus
- MCG experience preferred
- Knowledge of NCQA Preferred
- Certified Professional Coder (CPC) preferred
- Health Plan experience preferred
- Claims or post payment reconsideration experience is preferred
About Sentara Health Plans
Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.
Compensation
We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $93,350.40 - $132,433.60 annually. Additional compensation may be available for this role, such as shift differentials, standby/on-call pay, overtime, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.
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
- Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met