Clinical Claims Review Nurse

CVS Health•Work At Home-Texas, TX

2d•$29 - $62•Onsite

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.

Requirements

5+ years clinical experience required
2+ years of experience as a registered nurse
Must have active current and unrestricted RN licensure in the state of residence
Must have 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.
Must be willing to work Monday through Friday 8am – 5pm in the time zone of residence

Nice To Haves

Utilization Management review
Managed Care experience
Client processing experience

Responsibilities

Review and interpret clinical documentation obtained from medical records or systems.
Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims.
Coordinate clinical resolutions independently with clinician/MD support as required.
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 feedback to leadership if discrepancies or potential fraudulent activities are identified.
Remain current with applicable laws, regulations, and internal workflows to ensure compliance with organizational and state-specific requirements.