RN Clinical Claims Review Specialist (Post-Service)

CVS Health; New Mexico; Sur place; USD 36 000 - 77 000; Plein temps

Avantages offerts par ce poste

Medical, Dental, Vision coverage

Paid Time Off

Retirement savings options

Wellness programs

Résumé du poste

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate post-service claims against clinical criteria and policies. You will review documentation from medical records, apply regulatory requirements, and coordinate resolutions with clinicians.

This full-time role requires strong clinical judgment and attention to confidentiality, with a focus on accurate claim evaluation and adherence to company procedures.

Qualifications

• RN with nursing degree and active licensure.
• Minimum 2–3 years of professional RN experience.
• Knowledge of clinical documentation and claims review.

Responsabilités

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions with clinician/MD support.
• Serve as a resource for customer service and claims teams.
• Train staff and provide cross-training.
• Identify trends and report discrepancies or potential fraud.
• Ensure compliance with laws, regulations, and workflows.

Connaissances

Analytical skills

Nurse RN clinical experience

Formation

Associates Degree in Nursing

Bachelor of Science in Nursing

Outils

Microsoft Suite

Description du poste

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate post-service claims against clinical criteria and policies. You will review documentation from medical records, apply regulatory requirements, and coordinate resolutions with clinicians.

This full-time role requires strong clinical judgment and attention to confidentiality, with a focus on accurate claim evaluation and adherence to company procedures.