Virginia Licensed Clinical Claims Reviewer
Job Summary
To support effective utilization management, the full-time Virginia Licensed Clinical Claims Reviewer will conduct comprehensive claim reviews, authorization assessments, and provider inquiries in a remote setting, ensuring compliance with health plan policies and regulatory standards.
Key responsibilities
- Conduct pre and post-payment claim reviews and authorization assessments for various cases
- Address provider post-payment inquiries and ensure accurate coding in line with established guidelines
- Facilitate accreditation by interpreting and applying regulatory requirements and standards
Required qualifications
- Bachelor's Degree in Nursing (BSN) required
- Registered Nurse (RN) License (Compact or Virginia) required
- Minimum of 3 years of acute care clinical experience required
- Medical Coding certification required within 1 year of hire
- Experience in Utilization Review and Post Payment Review preferred
Complete Job Description
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