RN Clinical Claims Review Specialist

CVS Health; Connecticut; Presencial; USD 36 000 - 77 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Resumo da oferta

CVS Health is seeking a Clinical Claim Review Nurse in Connecticut to evaluate post-service claims using clinical criteria and regulatory guidelines. The role involves reviewing medical records, coordinating with clinicians, and ensuring adherence to confidentiality and company policies.

Responsibilities include training staff, supporting customer service and claims teams, and identifying trends to inform leadership. The position is full-time, with a generous benefits package and competitive pay.

Qualificações

• RN required with current license.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsabilidades

• Review documentation and interpret data from clinical records to apply clinical criteria and policies for member/provider claims.
• Coordinate clinical resolutions independently with clinician/MD support as required.
• Assist customer service and claims teams and provide training to staff.
• Ensure compliance with policies, regulations and confidentiality.
• Identify trends and flag potential fraudulent activities.

Conhecimentos

Analytical skills

Attention to detail

Communication skills

Formação académica

Associates Degree in Nursing

Bachelor of Science in Nursing (BSN)

RN licensure

Ferramentas

Microsoft Office

Descrição da oferta de emprego

CVS Health is seeking a Clinical Claim Review Nurse in Connecticut to evaluate post-service claims using clinical criteria and regulatory guidelines. The role involves reviewing medical records, coordinating with clinicians, and ensuring adherence to confidentiality and company policies.

Responsibilities include training staff, supporting customer service and claims teams, and identifying trends to inform leadership. The position is full-time, with a generous benefits package and competitive pay.