CVS Health
At CVS Health, weāre building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nationās leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues ā caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
As a QM Nurse Consultant you will be responsible for the review and evaluation of clinical information and documentation.
Required Qualifications: 5+ years of clinical experience required 2+ years of experience as a Registered Nurse Must have active, current and unrestricted RN licensure in state of residence 1+ years of 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 8:00am - 5:00pm in time zone of residence Preferred Qualifications: Utilization Management review Managed Care experience Education: Associates degree required
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. Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits. Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers. Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations. Adhere to company policies regarding confidentiality to protect member information.
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