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Clinical Claims Review Nurse
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Clinical Claims Review Nurse
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.
Required 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, and 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
Preferred Qualifications
- Utilization Management review
- Managed Care experience
- Client processing experience
Education
- Associates degree required
- BSN preferred
Anticipated Weekly Hours
40
Pay Range
The typical pay range for this role is
$29.10 – 62.32
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$29.10 - $62.32This 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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Additional Information
Company: CVS Health
Location: Texas
Salary: $29.10 - $62.32 per hour
Job ID: R1020736
Specialties: Managed Care, Utilization Management, Clinical Claims Review, Medical Claim Review
Required Licenses: RN
Experience Level: 5-10 years
