RN Claims Review Specialist: Clinical Judgment & Quality

CVS Health Corporation; Tennessee; Híbrido; USD 3 583 000 - 9 443 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical insurance

Dental coverage

Vision coverage

Paid time off

Retirement savings

Resumo da oferta

CVS Health Corporation is seeking a licensed Registered Nurse to review clinical documentation and apply decision-making criteria for post-service claims. The role coordinates resolutions with clinician support, serves as a knowledge resource for customer service and claims teams, and trains staff while monitoring for trends and compliance.

This is a full-time position based in Tennessee with a comprehensive benefits package.

Qualificações

• Active RN license in the state of residence.
• Nursing degree (RN).
• 2-3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsabilidades

• Review and interpret clinical documentation obtained from medical records or systems.
• Apply clinical decision-making to utilize appropriate clinical criteria 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.

Conhecimentos

Analytical skills

Formação académica

Bachelor's degree

Descrição da oferta de emprego

CVS Health Corporation is seeking a licensed Registered Nurse to review clinical documentation and apply decision-making criteria for post-service claims. The role coordinates resolutions with clinician support, serves as a knowledge resource for customer service and claims teams, and trains staff while monitoring for trends and compliance.

This is a full-time position based in Tennessee with a comprehensive benefits package.