Clinical Claims 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. This role requires the nurse to exercise clinical judgment and perform the following duties: 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 full compliance with organizational and state-specific requirements
Requirements
- Registered Nurse License in the state they reside
- 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
- Associates Degree in Nursing required
Nice To Haves
- Computer proficiency, Microsoft Suite
- Utilization Management experience
- Bachelor’s in Science and Nursing
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 full compliance with organizational and state-specific requirements
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.
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
