RN Clinical Claims Reviewer & Trainer

CVS Health; Pennsylvania; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is hiring a Clinical Claim Review Nurse to assess medical claims by reviewing clinical data and applying established criteria in accordance with policies and regulations. The role involves coordinating with clinicians to resolve complex cases and ensuring compliance with confidentiality requirements.

The position requires an RN license with 2–3 years of professional RN experience, strong analytical skills, and familiarity with utilization management.

Qualifications

• RN license required.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review documentation and interpret data from clinical records to apply appropriate clinical criteria and policies.
• Coordinate clinical resolutions with clinicians/MD support as needed.
• Review post-service claims for payment based on clinical policies, regulations, and plan benefits.
• Act as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training to teammates.
• Identify trends and report discrepancies or potential fraud.

Skills

Analytical skills

NCLEX RN

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Registered Nurse (RN) license

Tools

Microsoft Suite

Utilization Management

Job description

CVS Health is hiring a Clinical Claim Review Nurse to assess medical claims by reviewing clinical data and applying established criteria in accordance with policies and regulations. The role involves coordinating with clinicians to resolve complex cases and ensuring compliance with confidentiality requirements.

The position requires an RN license with 2–3 years of professional RN experience, strong analytical skills, and familiarity with utilization management.