RN — Clinical Claims Review Specialist

CVS Health; Sioux Falls (SD); In loco; USD 36.000 - 77.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical insurance

Dental insurance

Vision coverage

Paid time off

Retirement savings

Descrizione del lavoro

CVS Health in Sioux Falls, SD seeks a Clinical Claim Review Nurse to evaluate clinical information for member and provider claims, applying policy and regulatory criteria to determine payment decisions.

The role collaborates with clinicians, supports claims processing teams, trains staff, and identifies trends to improve accuracy and compliance. Requires RN license, 2–3 years of experience, strong analytical skills, and an Associate degree; BSN preferred. Full-time with comprehensive benefits.

Competenze

• RN license with 2–3 years of professional RN experience
• Strong analytical skills to assess medical claims

Mansioni

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions independently with clinician/MD support as required.
• Serve 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 leadership feedback on discrepancies or potential fraud.
• Stay current with applicable laws, regulations, and internal workflows to ensure compliance.

Conoscenze

RN

Clinical claims analysis

Analytical skills

MS Office

Utilization Management

Formazione

Associates Degree in Nursing

Bachelor of Science in Nursing preferred

Strumenti

Microsoft Office

Descrizione del lavoro

CVS Health in Sioux Falls, SD seeks a Clinical Claim Review Nurse to evaluate clinical information for member and provider claims, applying policy and regulatory criteria to determine payment decisions.

The role collaborates with clinicians, supports claims processing teams, trains staff, and identifies trends to improve accuracy and compliance. Requires RN license, 2–3 years of experience, strong analytical skills, and an Associate degree; BSN preferred. Full-time with comprehensive benefits.