RN Clinical Claims Reviewer—Impact & Compliance

CVS Health; Bismarck (ND); Sur place; USD 36 000 - 77 000; Plein temps

Résumé du poste

CVS Health is seeking a Clinical Claim Review Nurse who will review clinical information drawn from medical records, apply established clinical criteria, and evaluate post‑service claims to ensure accuracy and compliance with regulatory and plan requirements.

You will communicate findings, coordinate clinical resolutions with clinicians/MDs as needed, and act as a resource for customer service and claims processing teams, while upholding privacy standards.

Qualifications

• Nursing degree (RN) required.
• 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.
• Associates Degree in Nursing required; BSN preferred.

Responsabilités

• 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.

Connaissances

RN

Analytical skills

Formation

Associates Degree in Nursing

Bachelor of Science in Nursing

Outils

Microsoft Suite

Description du poste

CVS Health is seeking a Clinical Claim Review Nurse who will review clinical information drawn from medical records, apply established clinical criteria, and evaluate post‑service claims to ensure accuracy and compliance with regulatory and plan requirements.

You will communicate findings, coordinate clinical resolutions with clinicians/MDs as needed, and act as a resource for customer service and claims processing teams, while upholding privacy standards.