Clinical Claims Review RN — Analysis & Resolution

CVS Health; Michigan; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Wellness programs

Job summary

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate post-service medical claims by reviewing clinical documentation and applying appropriate criteria. The role requires RN licensure, 2–3 years of clinical experience, and strong analytical skills to support accurate payment decisions.

You will coordinate with clinicians and support teams while ensuring compliance with regulations and company policies.

Qualifications

• RN licensure and nursing degree.
• 2-3 years of professional experience as a licensed RN or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

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.

Skills

Strong analytical skills

Education

Associates Degree in Nursing required

Bachelor of Science in Nursing preferred

Tools

Microsoft Suite

Job description

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate post-service medical claims by reviewing clinical documentation and applying appropriate criteria. The role requires RN licensure, 2–3 years of clinical experience, and strong analytical skills to support accurate payment decisions.

You will coordinate with clinicians and support teams while ensuring compliance with regulations and company policies.