Clinical Claims Review Nurse: Accuracy & Compliance

CVS Health; Oklahoma; 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

Job summary

CVS Health is hiring a Clinical Claim Review Nurse in Oklahoma to evaluate post-service medical claims using established clinical criteria and policies. You will interpret documentation from medical records and coordinate resolutions with clinicians to ensure compliant outcomes.

The role requires an RN license and 2–3 years of clinical experience, with emphasis on accuracy, data interpretation, and adherence to regulatory requirements. Full-time position with comprehensive benefits.

Qualifications

• RN licensed with active nursing license and state registration.
• 2–3 years of professional experience as an RN or equivalent.
• Strong analytical skills to assess medical claims and documentation.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions independently with clinician/MD support as needed.
• Serve as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training to existing team members.
• Identify trends and report discrepancies or potential fraud to leadership.
• Maintain compliance with laws, regulations, and internal workflows.

Skills

Analytical skills

RN licensed

Utilization Management experience

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

CVS Health is hiring a Clinical Claim Review Nurse in Oklahoma to evaluate post-service medical claims using established clinical criteria and policies. You will interpret documentation from medical records and coordinate resolutions with clinicians to ensure compliant outcomes.

The role requires an RN license and 2–3 years of clinical experience, with emphasis on accuracy, data interpretation, and adherence to regulatory requirements. Full-time position with comprehensive benefits.