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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
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.
Requirements
Anticipated Weekly Hours: 40.
Time Type: Full time.
Pay Range: The typical pay range for this role is $26.01 - $68.55.
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 and competitive mix of pay and benefits.
Medical, dental, and vision coverage.
Paid time off.
Retirement savings options.
Wellness programs and other resources, based on eligibility.
