[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 full compliance with organizational and state-specific requirements.

Qualifications

• Must have active current and unrestricted Registered Nurse 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.
• Education: Bachelor's degree.

Requirements

• Anticipated Weekly Hours: 40.
• Time Type: Full time.
• Pay Range: The typical pay range for this role is $26.01 - $68.55.
• This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.
• The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.
• This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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.
• Additional details about available benefits are provided during the application process.