Clinical Claim Review Nurse

CVS Health; Philadelphia (Philadelphia County); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Comprehensive benefits package

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in the United States to evaluate clinical documentation and apply appropriate criteria to post-service claims. You will coordinate resolutions with clinicians, support customer service and claims teams, and train staff while ensuring compliance with regulatory requirements.

The role emphasizes confidentiality, accuracy, and ongoing awareness of state and federal regulations.

Qualifications

• RN with nursing degree and active RN license.
• 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation for post-service claims.
• Apply clinical criteria and policies to claim reviews.
• Coordinate clinical resolutions independently with clinician/MD support.
• Serve as a resource for customer service and claims teams.
• Train new staff and cross-train existing team members.
• Identify trends and report discrepancies or potential fraud.
• Ensure compliance with laws, regulations and workflows.

Skills

Analytical skills

RN licensed

Utilization Management experience

Microsoft Office

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

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.

Role Summary

As a Clinical Claim Review Nurse you will be 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. 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.

Key Responsibilities

• 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

• 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.

Preferred Qualifications

• Computer proficiency, Microsoft Suite
• Utilization Management experience

Education

• Associates Degree in Nursing required
• Bachelor of Science and Nursing preferred

Work Hours & Time Type

• Anticipated Weekly Hours: 40
• Time Type: Full time

Pay Range

• The typical pay range for this role is: $26.01 - $56.14
• 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.

Benefits

• 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.

Closing Deadline

We anticipate the application window for this opening will close on: 11/05/2026

Background Check Statement

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.