Clinical Claim Review Nurse
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. As a Clinical Claim Review Nurse you will be responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits. Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers. Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations. Adhere to company policies regarding confidentiality to protect member information.
Requirements
- 5+ years of clinical experience required
- 2+ years of experience as a Registered Nurse
- Must have active, current and unrestricted RN licensure in state of residence
- 1+ years of experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews.
- Associates Degree in Nursing required
Nice To Haves
- Managed Care experience
- Bachelor of Science and Nursing preferred
Responsibilities
- Responsible for the review and evaluation of clinical information and documentation.
- Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims.
- Independently coordinates the clinical resolution with clinician/MD support as required.
- Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits.
- Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers.
- Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations.
- Adhere to company policies regarding confidentiality to protect member information.
Benefits
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
