RN Clinical Claims Review Specialist

CVS Health Corporation; Kansas; Hybrid; USD 74,530,000 - 196,424,000; Full time

Benefits offered by this job

Medical benefits

Dental and Vision coverage

Performance bonus

Job summary

CVS Health Corporation is seeking a registered nurse navigator to review clinical documentation, apply decision criteria for post-service claims, and coordinate resolutions with clinicians as needed. The role emphasizes compliance with laws, policies, and quality standards, with ongoing staff training and process improvement.

The position involves analyzing medical claims, interpreting records, and providing support to customer service and claims teams within a full‑time schedule.

Qualifications

• Must have active current and unrestricted Registered Nurse licensure in state of residence.
• Nursing degree (RN)
• A minimum of 2-3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience
• Strong analytical skills to assess medical claims

Responsibilities

• Review and interpret clinical documentation obtained 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

RN licensure

Analytical skills

Education

Bachelor's degree

Job description

CVS Health Corporation is seeking a registered nurse navigator to review clinical documentation, apply decision criteria for post-service claims, and coordinate resolutions with clinicians as needed. The role emphasizes compliance with laws, policies, and quality standards, with ongoing staff training and process improvement.

The position involves analyzing medical claims, interpreting records, and providing support to customer service and claims teams within a full‑time schedule.