Clinical Claim Review Nurse

Job not on LinkedIn

🔥 0 minutes ago

🏈 Alabama, Alaska, +43 more states – Remote

🏈 Alabama – Remote 🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🌺 Hawaii – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Review and evaluate clinical information and documentation • Interpret data from clinical records or systems and apply appropriate clinical criteria and policies to post-service claims • Coordinate clinical resolutions independently, with clinician/MD support as required • Evaluate claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits • Navigate multiple system applications and outreach to internal departments or providers as needed • 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 regarding discrepancies or potential fraudulent activities • Remain current with applicable laws, regulations, and internal workflows to ensure compliance • Protect member information by adhering to confidentiality policies

🎯 Requirements

• Nursing degree (RN) • Associates Degree in Nursing required • 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 • Computer proficiency, Microsoft Suite • Utilization Management experience preferred • Bachelor of Science and Nursing preferred • Ability to comply with applicable laws, regulations, company policies, procedures, confidentiality requirements, and state-specific requirements

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to the base pay range • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility