RN: Clinical Claims Review & Resolution Expert

CVS Health; New Jersey; Vor Ort; USD 36.000 - 77.000; Vollzeit

Benefits dieser Stelle

Medical coverage

Dental and vision

401(k)

Zusammenfassung

CVS Health in New Jersey is seeking a Clinical Claim Review Nurse to evaluate clinical information and documentation for post-service claims. The role requires RN licensure and 2–3 years of professional experience with strong analytical skills.

You will review medical records, apply clinical criteria, and coordinate resolutions with clinicians as needed. The position offers comprehensive benefits and a collaborative, patient-centered environment.

Qualifikationen

• RN licensed with a nursing degree.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Aufgaben

• Reviews documentation and interprets data from clinical records to apply clinical criteria and policies for member and/or provider claims.
• Coordinates clinical resolutions independently with clinician/MD support as required.
• Evaluates post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits.
• Navigates multiple system applications and may outreach to internal departments or providers.
• Ensures confidentiality to protect member information and comply with laws and company policies.
• Trains new staff and provides cross-training to team members.

Kenntnisse

RN

Analytical skills

Claims analysis

Ausbildung

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Jobbeschreibung

CVS Health in New Jersey is seeking a Clinical Claim Review Nurse to evaluate clinical information and documentation for post-service claims. The role requires RN licensure and 2–3 years of professional experience with strong analytical skills.

You will review medical records, apply clinical criteria, and coordinate resolutions with clinicians as needed. The position offers comprehensive benefits and a collaborative, patient-centered environment.