RN Clinical Claims Review Specialist

CVS Health; Madison (WI); In loco; USD 36.000 - 77.000; Tempo pieno

Descrizione del lavoro

CVS Health in Madison, WI seeks a Clinical Claim Review Nurse (RN) to review and evaluate clinical information and documentation for member and provider claims. You will apply clinical criteria in line with regulatory requirements and coordinate resolutions with clinician support as needed.

The role requires an RN with 2–3 years of professional experience and strong analytical abilities to assess medical claims, while adhering to confidentiality and state regulations.

Competenze

• Nursing degree (RN) required.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.
• Associates Degree in Nursing required; Bachelor of Science in Nursing preferred.

Mansioni

• 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.

Conoscenze

RN experience

Analytical skills

Communication

Formazione

Associates Degree in Nursing

BSN preferred

Strumenti

Microsoft Suite

Descrizione del lavoro

CVS Health in Madison, WI seeks a Clinical Claim Review Nurse (RN) to review and evaluate clinical information and documentation for member and provider claims. You will apply clinical criteria in line with regulatory requirements and coordinate resolutions with clinician support as needed.

The role requires an RN with 2–3 years of professional experience and strong analytical abilities to assess medical claims, while adhering to confidentiality and state regulations.