Clinical Claim Review Nurse
About The Position
As a Clinical Claim Review Nurse, you review and evaluate clinical information and documentation for post-service member and/or provider claims. You interpret data from clinical records and systems and use clinical judgment to apply appropriate clinical criteria, policies, plan benefits, and applicable legislation, regulatory, and accreditation requirements. You coordinate clinical resolutions independently, with clinician or physician support when needed, and may navigate multiple systems or contact internal departments and providers. You also help customer service and claims processing teams, train staff, identify trends or possible discrepancies and fraudulent activity, and stay current with laws, regulations, and internal workflows. The role requires protecting member information and following company policies and applicable state and federal requirements.
Requirements
- Nursing degree (RN).
- A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience.
- Strong analytical skills to assess medical claims.
Nice To Haves
- Computer proficiency, including Microsoft Suite.
- Utilization Management experience.
- Bachelor of Science in Nursing preferred.
Responsibilities
- Review and interpret clinical documentation obtained from medical records or systems.
- Apply clinical decision-making and appropriate clinical criteria and policies to post-service claims.
- Coordinate clinical resolutions independently, with clinician or physician support as required.
- Evaluate post-service claims for payment using medical records, system documentation, clinical policies, legislation, regulatory requirements, and plan benefits.
- Navigate multiple system applications and, when needed, contact internal departments or providers.
- Apply review requirements in accordance with company policies and procedures and state and federal laws and regulations.
- Protect member information by adhering to company confidentiality policies.
- Act as a resource for customer service and claims processing teams.
- Train new staff and provide cross-training to existing team members.
- Identify trends and provide leadership with feedback about discrepancies or potential fraudulent activities.
- Remain current with applicable laws, regulations, and internal workflows.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
