RN Clinical Claims Reviewer & Compliance Advocate

CVS Health Corporation; Colorado; Hybrid; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid time off

Retirement plan

Wellness programs

Job summary

CVS Health Corporation in the United States is seeking a Registered Nurse to review clinical documentation, apply clinical decision-making to post-service claims, and coordinate resolutions with clinicians as needed.

This full-time role involves training staff, identifying trends, and maintaining compliance with laws and internal workflows while collaborating with customer service and claims teams. The position includes a comprehensive benefits package for eligible employees.

Qualifications

• Must have active RN licensure in state of residence.
• Nursing degree (RN).
• A minimum of 2-3 years of professional experience as a licensed RN, or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• 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.

Skills

Analytical skills

Education

RN license

Bachelor's degree in Nursing

Job description

CVS Health Corporation in the United States is seeking a Registered Nurse to review clinical documentation, apply clinical decision-making to post-service claims, and coordinate resolutions with clinicians as needed.

This full-time role involves training staff, identifying trends, and maintaining compliance with laws and internal workflows while collaborating with customer service and claims teams. The position includes a comprehensive benefits package for eligible employees.