RN Claims Review & Training Specialist

CVS Health Corporation; Georgia; Hybrid; USD 36,000 - 94,000; Full time

Job summary

CVS Health Corporation in the United States is seeking a registered nurse to review and interpret clinical documentation from medical records, apply clinical criteria to post-service claims, and coordinate resolutions independently with clinician support as required. The role trains staff, identifies trends, and ensures compliance with applicable laws and internal workflows.

A Bachelor’s degree in nursing and active RN licensure are required, with 2–3 years of RN experience.

Qualifications

• Strong analytical skills to assess medical claims.
• Active current and unrestricted RN licensure in state of residence.
• Bachelor's degree in Nursing (RN).

Responsibilities

• Review and interpret clinical documentation 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.

Skills

Analytical skills

Education

Bachelor's degree in Nursing (RN)

Registered Nurse licensure (RN)

Job description

CVS Health Corporation in the United States is seeking a registered nurse to review and interpret clinical documentation from medical records, apply clinical criteria to post-service claims, and coordinate resolutions independently with clinician support as required. The role trains staff, identifies trends, and ensures compliance with applicable laws and internal workflows.

A Bachelor’s degree in nursing and active RN licensure are required, with 2–3 years of RN experience.