Clinical Claims Review RN - Analyze & Resolve Post-Service Claims

CVS Health; North Dakota; Vor Ort; USD 36.000 - 77.000; Vollzeit

Benefits dieser Stelle

Medical insurance

Dental insurance

Vision coverage

Paid time off

Retirement plan

Wellness programs

Zusammenfassung

CVS Health is seeking a Clinical Claim Review Nurse to assess medical documentation and apply clinical criteria for post-service claims. The role requires RN licensure and 2-3 years of experience, plus strong analytical skills.

You will coordinate resolutions with clinicians and support teams, train staff, and ensure compliance with laws and internal policies. The position offers a full-time schedule with typical healthcare benefits and opportunities to contribute to cross-functional teams

Qualifikationen

• Nursing degree (RN) required.
• A minimum of 2-3 years of professional experience as a licensed Registered Nurse (RN) or equivalent.
• Strong analytical skills to assess medical claims.

Aufgaben

• 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.

Kenntnisse

Strong analytical skills

Utilization Management experience

Ausbildung

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Jobbeschreibung

CVS Health is seeking a Clinical Claim Review Nurse to assess medical documentation and apply clinical criteria for post-service claims. The role requires RN licensure and 2-3 years of experience, plus strong analytical skills.

You will coordinate resolutions with clinicians and support teams, train staff, and ensure compliance with laws and internal policies. The position offers a full-time schedule with typical healthcare benefits and opportunities to contribute to cross-functional teams