RN Clinical Claims Reviewer & Quality Advocate

CVS Health Corporation; Vermont; Hybrid; USD 54.000 - 143.000; Vollzeit

Zusammenfassung

CVS Health Corporation is seeking a licensed Registered Nurse to interpret clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinical support. The role emphasizes adherence to state and organizational policies, training teammates, and identifying trends for quality assurance.

Upholding regulatory compliance and delivering reliable customer service, this full-time position offers a comprehensive benefits package as part of CVS Health's

Qualifikationen

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

Aufgaben

• 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

Kenntnisse

Analytical skills

Ausbildung

RN licensure (active, unrestricted)

Bachelor's degree

Jobbeschreibung

CVS Health Corporation is seeking a licensed Registered Nurse to interpret clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinical support. The role emphasizes adherence to state and organizational policies, training teammates, and identifying trends for quality assurance.

Upholding regulatory compliance and delivering reliable customer service, this full-time position offers a comprehensive benefits package as part of CVS Health's