RN Clinical Claims Review Specialist

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

Vantaggi offerti da questo lavoro

Bonus eligibility

Comprehensive benefits

Paid time off

Descrizione del lavoro

CVS Health in Madison, WI is seeking a Clinical Claim Review Nurse to evaluate and adjudicate post-service claims using clinical criteria and policies, in compliance with state and federal regulations.

You will interpret documentation from medical records, coordinate with clinicians, support customer service and claims teams, and train new staff while staying current with applicable laws and internal workflows.

Competenze

• RN degree and current license.
• 2–3 years of RN experience.
• Strong analytical skills to assess medical claims.
• Associates Degree in Nursing required; BSN preferred.
• Proficiency with Microsoft Office and utilization management experience preferred.

Mansioni

• Review and interpret clinical documentation from medical records.
• Apply clinical criteria and policies to post-service claims.
• Coordinate resolutions with clinicians as needed.
• Serve as a resource for customer service and claims teams.
• Train new staff and cross-train existing team members.
• Identify trends and report discrepancies or potential fraud.
• Stay compliant with laws, regulations, and internal workflows.

Conoscenze

RN experience

Analytical skills

Formazione

Associates Degree in Nursing

Bachelor of Science in Nursing

Strumenti

Microsoft Office

Descrizione del lavoro

CVS Health in Madison, WI is seeking a Clinical Claim Review Nurse to evaluate and adjudicate post-service claims using clinical criteria and policies, in compliance with state and federal regulations.

You will interpret documentation from medical records, coordinate with clinicians, support customer service and claims teams, and train new staff while staying current with applicable laws and internal workflows.