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Bringing our heart to every moment of your health.
Clinical Claims Review Nurse
Location
United States + 1 moreAll locations: United States | Bermuda
Posted
72 days ago
Salary
$29 - $62 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Claims Review Nurse
CVS Health
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. - 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 Required Qualifications: - A minimum of 2–3 years of professional experience as a licensed - Registered Nurse (RN) Licensure in the state they reside - Strong analytical skills to assess medical claims Preferred Qualifications: - Computer proficiency, Microsoft Suite - Utilization Management experience Education: - Bachelor’s in Science and Nursing Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This 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. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 04/13/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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Terumo BCT, Inc.Our ability to grow, develop new capabilities and serve even more patients around the world depends on associates like you, who are passionate about our mission. Thank you for considering this new opportunity to further unlock your potential.
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Terumo Blood and Cell Technologies is committed to providing a safe, healthy and secure working environment. Our Colorado campus locations are tobacco-free workplaces, and we maintain a drug-free workplace and perform pre-employment substance abuse testing and detailed background verification.
Senior Specialist, Clinical Documentation
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• Support all care teams across the region in comprehensive and targeted chart reviews • Facilitate efficient and effective medical care for our patients • Partner with regional leaders, including the Population Health Director and Senior CIS • Prepare and lead monthly Rejected Suspect Reviews • Identify and analyze opportunities for improving patient quality outcomes and cost of care • Monitor clinical documentation efforts • Other duties, as assigned
Clinical UM Registered Nurse
CenterWellCenterWell Pharmacy provides convenient, safe, reliable pharmacy services and is committed to excellence and quality. Through our home delivery and over-the-counter fulfillment services, specialty, and retail pharmacy locations, we provide customers simple, integrated solutions every time. Cares for patients with chronic and complex illnesses. Offers personalized clinical and educational services to improve health outcomes and drive superior medication adherence. CenterWell, a Humana company, creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and the fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional, and social wellness of our patients. Part of Humana Inc. (NYSE: HUM). Offers stability, industry-leading benefits, and opportunities to grow yourself and your career. Employs more than 30,000 clinicians committed to putting health first. Provides flexible scheduling options, clinical certifications, leadership development programs, and career coaching.
Become a part of our caring community As a Utilization Management Nurse 2, you will use clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. You will understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. 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Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. 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(NYSE: HUM). Learn more about what we offer at CenterWell.com. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Mid-Term Review (MTR) Team Leader
Food and Agriculture Organization (FAO)The Food and Agriculture Organization of the United Nations (FAO) contributes to the achievement of the 2030 Agenda through the FAO Strategic Framework by supporting the transformation to more efficient, inclusive, resilient, and sustainable agrifood systems. FAO leads international efforts to defeat hunger and achieve food security for all. Works in over 130 countries worldwide with 195 Members. Offers policy advice and support to countries in the mandated areas of FAO. Ensures effective and efficient operations with adequate human and financial resources.
Organizational Setting The Food and Agriculture Organization of the United Nations (FAO) contributes to the achievement of the 2030 Agenda through the FAO Strategic Framework by supporting the transformation to MORE efficient, inclusive, resilient and sustainable agrifood systems, for better production, better nutrition, a better environment and a better life, leaving no one behind. FAO is a specialized agency of the UN that leads international efforts to defeat hunger. FAO's goal is to achieve food security for all and ensure that people have regular access to enough high-quality food to lead active, healthy lives. With 195 Members (194 countries and the European Union), FAO works in over 130 countries worldwide. FAO Country Offices, working under overall corporate guidance and in line with the Strategic Framework, offer policy advice and support to countries in the mandated areas of FAO, facilitated through partnerships, resources and an active country programme to provide technical assistance, develop capacities and deliver core services while fully observing international standards of accountability to establish leadership and strengthen impact at the country level. The offices deliver on the programmatic priorities of each country as agreed in their respective Country Programming Frameworks (CPFs) aligned to the UN Sustainable Development Cooperation Framework (UNSDCF) and ensure effective and efficient operations with adequate human and financial resources. Specifically, FAO Country Offices: (i) advocate, inform and support policies and investments in the areas of FAO’s mandate; (i) provide technical assistance and deliver core services; (iii) assist and catalyse partnership and resource mobilization activities to support agrifood systems transformation; (iv) position FAO as the specialized/authoritative technical agency in food and agriculture and agrifood systems transformation; and (v) ensure risk-smart and accountable operations and management. FAO is one of the lead Implementing Agencies of the Global Environment Facility (GEF), with a portfolio of almost 150 active projects funded by the facility, in all regions. All GEF-funded full-size projects must undergo a mid-term review (MTR) under the GEF evaluation policy. The FAO Guide for planning and conducting mid-term reviews provides corporate guidance on planning, formulating, and conducting MTRs for projects and programmes implemented by FAO that have received grant financing from the GEF Trust Fund. The GEF-funded project “Enhancing biodiversity, maintaining ecosystem flows, enhancing carbon stocks through sustainable land management, and the restoration of degraded forestlands (FSP)” is being implemented by the FAO Office Philippines and executed via the Operational Partner Implementation Modality (OPIM) with the Department of Environment and Natural Resources through the Forest Management Bureau. This project seeks to provide multiple, integrated environmental, social, and economic benefits through cost-effective and sustainable restoration of degraded forests and landscapes. The project is at the mid-point of its planned implementation duration and is now required to conduct MTR. Reporting Lines The MTR Team Leader will report to the FAO GEF Coordination Unit Monitoring and Reporting Officer in coordination with the FAO MTR Manager. Technical Focus The MTR Team Leader will be responsible for coordinating the MTR consulting team’s contribution to the project’s MTR and ensuring that the final MTR report is prepared. Tasks and responsibilities • Review relevant background documentation made available by the designated MTR manager and project team, including the project document, the project’s logframe, progress and final reports, workshop and technical reports, among others as listed in the MTR terms of reference; • Review and complement (expand as appropriate) the methodology described in the MTR terms of reference, prepare data-collection tools, including questionnaires, checklists and interview protocols as appropriate; • Coordinate preparation, drafting and finalization of the MTR inception report, including an MTR matrix, theory of change and stakeholder table, and participate in the finalization of the team’s work programme; • Lead and coordinate the collection of primary data by the MTR team through interviews and meetings (face-to-face or virtual) with relevant FAO officers in headquarters and/or Project Coordination Unit, among other things, and during country visits with key stakeholders including the government, FAO Representatives, external partners, project teams, international organizations, the private sector, civil society, academia, research institutes and ultimate beneficiaries, as appropriate, as described in the MTR terms of reference; • By working with National MTR Consultants, coordinate the collection of primary data by the MTR team during country visits and relevant secondary data, according to the methodology presented in the MTR terms of reference and detailed in the inception report; • Lead the analysis and discussion of evidence collected within the MTR team to identify key findings and preliminary conclusions that respond to the MTR’s issues and questions, and formulate preliminary recommendations in line with the findings and conclusions; • Ensure that all the findings are sufficiently triangulated and validated; • Present the preliminary MTR findings to key stakeholders, as required; • Lead, coordinate and prepare all deliverables planned in the MTR terms of reference, according to specifications provided in the terms of reference and detailed in the FAO–GEF MTR Guide and annexes; • Coordinate the participation and contribution of team members in all deliverables, as required; • Lead the preparation of the first and second drafts of the MTR report, integrate comments received, as appropriate, from the Budget Holder, FAO-GEF Coordination Unit, other FAO and government agency staff, and other relevant stakeholders, as appropriate; • Lead the finalization of the MTR report and coordinate the inputs of other members of the MTR team into the final version, as needed. • The consultant may also be requested to perform other on-demand duties to the GEF Coordination Unit relating to project design, implementation and reporting, as required. CANDIDATES WILL BE ASSESSED AGAINST THE FOLLOWING Minimum Requirements • An advanced university degree from an institution recognized by the International Association of Universities (IAU)/UNESCO in evaluation, forestry, natural-resource management or a related field. Consultants with bachelor's degree need two additional years of relevant professional experience. • Ten years of relevant experience in supporting, designing, planning and/or conducting development evaluations • Working knowledge (level C) of English FAO Core Competencies • Results Focus • Teamwork • Communication • Building Effective Relationships • Knowledge Sharing and Continuous Improvement Technical/Functional Skills • Experience in conducting evaluations of agriculture related and natural-resource management projects/programs • Knowledge of FAO and GEF work/procedures, or other UN agencies, would be an asset. • A demonstration of the following competencies – results driven, teamwork, communications, relationship-building, and knowledge management
