RN Clinical Claims Review Specialist

CVS Health Corporation; Connecticut; Hybrid; USD 54,000 - 143,000; Full time

Job summary

CVS Health is seeking a Registered Nurse to review clinical documentation and apply decision-making for post-service claims. The role requires an active RN license, a nursing degree, and 2-3 years of RN experience. You will analyze medical claims and support customer service and claims teams.

The role emphasizes compliance with laws and internal workflows, with a 40-hour workweek and full benefits. CVS Health offers a strong benefits package and opportunities for professional development.

Qualifications

• Must have active current and unrestricted RN licensure in state of residence.
• Nursing degree (RN).
• Minimum 2-3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to use 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

Clinical judgment

Education

Bachelor's degree

Job description

CVS Health is seeking a Registered Nurse to review clinical documentation and apply decision-making for post-service claims. The role requires an active RN license, a nursing degree, and 2-3 years of RN experience. You will analyze medical claims and support customer service and claims teams.

The role emphasizes compliance with laws and internal workflows, with a 40-hour workweek and full benefits. CVS Health offers a strong benefits package and opportunities for professional development.