CLINICAL CLAIMS REVIEWER
Virginia Beach, VA 
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Posted 1 month ago
Job Description

City/State

Virginia Beach, VA

Overview

Work Shift

First (Days) (United States of America)

Job Summary

Responsible for the coordination, investigation, documentation and resolution of provider inquiries and reconsiderations ensuring compliance with Optima Health policy and procedures and other regulatory agency standard guidelines; review of procedures for post-authorization based on medical necessity, medical and behavioral health standards of care, and benefit determinations; review of suspended claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization; will utilize knowledge of correct coding guidelines, CMS Correct Coding Initiative edits, Optima Health Coding policies, Milliman Criteria, Clinical Care Services Medical Policies and group benefits to determine appropriate claim approval/denials; will provide coding justifications for denials to providers; will identify trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities.

CPC within 1 year of eligibility. If RN candidate is not BSN prepared must be willing to sign an education agreement upon hire to complete BSN within 60 months of hire date, otherwise will not be considered.

Qualifications:

BLD - Bachelor's Level Degree (Required)

Registered Nurse License (RN) - Alabama State, Registered Nurse License (RN) - Alabama State, Registered Nurse License (RN) - Arizona State, Registered Nurse License (RN) - Arkansas State, Registered Nurse License (RN) - Colorado State, Registered Nurse License (RN) - Delaware State, Registered Nurse License (RN) - Florida State, Registered Nurse License (RN) - Georgia State, Registered Nurse License (RN) - Idaho State, Registered Nurse License (RN) - Indiana State, Registered Nurse License (RN) - Iowa State, Registered Nurse License (RN) - Kansas State, Registered Nurse License (RN) - Kentucky State, Registered Nurse License (RN) - Louisiana State, Registered Nurse License (RN) - Maine State, Registered Nurse License (RN) - Maryland State, Registered Nurse License (RN) - Mississippi State, Registered Nurse License (RN) - Missouri State, Registered Nurse License (RN) - Montana State, Registered Nurse License (RN) - Nebraska State, Registered Nurse License (RN) - New Hampshire State, Registered Nurse License (RN) - New Jersey State, Registered Nurse License (RN) - New Mexico State, Registered Nurse License (RN) - North Carolina State, Registered Nurse License (RN) - North Dakota State {+ 10 more}

Acute Care

Skills

Coding, Service Orientation, Technology/Computer

Sentara Healthcare 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.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.


In support of our mission "to improve health every day," this is a tobacco-free environment.

 

Job Summary
Company
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Bachelor's Degree
Required Experience
Open
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