临床理赔审核员/注册护士
Clinical Claims Reviewer/ RN
城市/州
弗吉尼亚州诺福克
工作班次
第一班（日班）
简介：
Sentara Health Plans 正在招聘一名临床理赔审核员/注册护士 - 远程！
职位状态：全职，长期职位（40小时/周）
标准工作时间：美国东部时间上午8点至下午5点，周一至周五。
远程工作机会提供于以下各州：弗吉尼亚州、北卡罗来纳州、阿拉巴马州、特拉华州、佛罗里达州、佐治亚州、爱达荷州、印第安纳州、堪萨斯州、路易斯安那州、缅因州、马里兰州、明尼苏达州、内布拉斯加州、内华达州、新罕布什尔州、北达科他州、俄亥俄州、俄克拉荷马州、宾夕法尼亚州、南卡罗来纳州、南达科他州、田纳西州、德克萨斯州、犹他州、华盛顿州、西弗吉尼亚州、威斯康星州、怀俄明州
职位职责：
- 注册护士临床医生负责在其执照范围内执行利用管理服务。主要职责包括进行理赔审核，涵盖付款前和付款后，以及住院、门诊、同时和回顾性病例的授权审核。该职位还处理供应商付款后的查询和重新考虑，必要时将案件转交医疗总监。确保符合健康计划政策及其他监管机构的要求，如保险局（BOI）、国家质量保证委员会（NCQA）、医疗保险和医疗补助服务中心（CMS）以及弗吉尼亚州医疗援助服务部（DMAS）。审核依据会员资格和福利、健康计划医疗政策、供应商特定指南和政策、MCG、DMAS 和 CMS 标准，根据会员的计划进行。负责向供应商（LOB 专属）书面通知审核决定。通过了解、理解、正确解释并准确应用认证和监管要求及标准，促进认证。
- 注册护士临床医生负责审核供应商付款后的查询和理赔重新考虑，以确保编码符合既定的编码指南、CMS 指南、健康计划编码支付政策和理赔支付政策。这包括评估正确的代码选择、适当使用修饰符、代码捆绑、未列出的代码、过多的同类型程序、与诊断不兼容的程序、超过最大频率以及其它编码编辑。注册护士运用临床知识和编码专业知识，以促进合规性、准确性和适当的报销。需要注册护士学士学位（BSN）。必须具备3年急症护理临床经验。有利用审查和付款后审查经验者优先。
查看英文原文
City/State
Norfolk, VAWork Shift
First (Days)Overview:
Sentara Health Plans is hiring a Clinical Claims Reviewer/ RN - Remote!
Status: Full-time, permanent position (40 hours)
Standard working hours: 8am to 5pm EST, M-F.
Remote opportunities available in the following states: 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 (state), West Virginia, Wisconsin, Wyoming
Job responsibilities:
- 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. Ensures 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). Reviews are 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. Responsible for written notification of review decision to providers (LOB specific). Facilitates accreditation by knowing, understanding, correctly interpreting and accurately applying accrediting and regulatory requirements and standards.
- RN Clinician is responsible for 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. This includes 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. RN Clinician applies clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement. RN BSN Required. Must possess 3 years of acute care clinical experience. Previous Utilization Review and Post Payment Review a plus. MCG experience preferred. Knowledge of NCQA Preferred. Requires strong verbal, written and interpersonal communication skills, problem solving skills, facilitation skills and analytic skills. Medical Coding certification required within 1 year of hire.
Education:
· Bachelors Degree in Nursing REQUIRED
Certification/Licensure
- Registered Nurse (RN) License (Compact or Virginia) REQUIRED
- Certified Professional Coder (CPC) preferred
Experience:
- 3 years of acute care clinical experience REQUIRED
- Health Plan experience preferred
- Claims or post payment reconsideration experience is preferred
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.
We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $66,830.4 – $111,384. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities
Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.
Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!
To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-105056
Talroo - Nursing
Clinical Claims Reviewer, Appeals, Denials, Utilization management, Registered Nurse, BSN, ADN, Nursing, Managed Care, MCO, Health Plan, Virginia, RN, VA, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (state), West Virginia, Wisconsin, Wyoming
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: Caring For Your Family and Your Career
• 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.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission “to improve health every day,” this is a tobacco-free environment.
For positions that are available as remote work,Sentara Health employs associates in the following states:
Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
Originally posted on Himalayas