[Hiring] Clinical Claims Reviewer @Sentara Health

Role Description

Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote!

• 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.
  • Authorization review covering inpatient, outpatient, concurrent, and retrospective cases.
  • Addressing provider post-payment inquiries and reconsiderations.
  • Ensuring compliance with health plan policy and regulatory agencies.
  • Reviewing based on member eligibility and benefits, health plan medical policy, and other guidelines.
  • Responsible for written notification of review decision to providers.
  • Facilitating accreditation by applying accrediting and regulatory requirements.
• Responsible for reviewing provider post-payment inquiries and claim reconsiderations to ensure accurate coding, including:
  • Evaluating correct code selection.
  • Appropriate use of modifiers.
  • Code bundling and unlisted codes.
  • Excessive procedures of the same type.
  • Procedures incompatible with the diagnosis.
  • Maximum frequency exceeded and other coding edits.
• Applies clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement.

Qualifications

• Bachelors Degree in Nursing (REQUIRED)
• Registered Nurse (RN) License (Compact or Virginia) (REQUIRED)
• Certified Professional Coder (CPC) (preferred)
• 3 years of acute care clinical experience (REQUIRED)
• Health Plan experience (preferred)
• Claims or post payment reconsideration experience (preferred)

Requirements

• Medical Coding certification required within 1 year of hire.
• Strong verbal, written, and interpersonal communication skills.
• Problem-solving skills and facilitation skills.
• Analytic skills.

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
• Annual discretionary bonus opportunity based on eligibility criteria.