[Hiring] Clinical Claims Review Nurse @CVS Health

Role Description

This role requires the nurse to exercise clinical judgment and perform the following duties:

• 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 compliance with organizational and state-specific requirements.

Qualifications

• 5+ years clinical experience required
• 2+ years of experience as a registered nurse
• Must have active current and unrestricted RN licensure in the state of residence
• Must have experience using Microsoft Office products including Outlook and Excel
• Previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews
• Must be willing to work Monday through Friday 8am – 5pm in the time zone of residence

Requirements

• Utilization Management review (preferred)
• Managed Care experience (preferred)
• Client processing experience (preferred)

Education

• Associates degree required
• BSN preferred

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources, based on eligibility