RN Clinical Claims Reviewer

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

Avantages offerts par ce poste

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Résumé du poste

CVS Health is seeking a Clinical Claim Review Nurse in the United States to evaluate clinical information and determine claim payment eligibility based on policies and regulations. The role requires RN licensure, 2–3 years of RN experience, and strong analytical skills to assess medical claims.

The position involves coordinating with clinicians, supporting customer service teams, training staff, and ensuring confidentiality of member information while complying with state and federal laws.

Qualifications

• RN nursing degree required.
• 2–3 years of professional RN experience required.
• Strong analytical skills to assess medical claims.

Responsabilités

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

Connaissances

RNlicensure/Registered Nurse

Analytical skills

Utilization Management

Microsoft Office

Formation

Associates Degree in Nursing

Bachelor of Science in Nursing (preferred)

Outils

Microsoft Office

Description du poste

CVS Health is seeking a Clinical Claim Review Nurse in the United States to evaluate clinical information and determine claim payment eligibility based on policies and regulations. The role requires RN licensure, 2–3 years of RN experience, and strong analytical skills to assess medical claims.

The position involves coordinating with clinicians, supporting customer service teams, training staff, and ensuring confidentiality of member information while complying with state and federal laws.