Job description

Responsible for the review and evaluation of clinical
information and documentation. Reviews documentation
and interprets data obtained from clinical records or
systems and uses clinical decision-making to apply
appropriate clinical criteria and policies in line with
regulatory and accreditation requirements for member
and/or provider claims. Independently coordinates the
clinical resolution with clinician/MD support as required.
Acts as a resource for customer service and claims
processing areas. Requires an RN with unrestricted active
license.

Pay Range
The typical pay range for this role is:
Minimum: 58,760
Maximum: 125,840

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications
2+ years of clinical experience required
RN with current unrestricted state licensure required
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

Preferred Qualifications
Experience with ATV, ASD, MedCompass, HRP, or clinical/therapy review experience preferred

Education
ADN or BSN preferred

Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

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