Clinical Claims Review RN — Analyze & Resolve Post-Service Claims

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate clinical information and determine payment on member and provider claims according to policies and regulations. The role requires interpreting medical records, applying criteria, and collaborating with clinicians to resolve complex cases.

The ideal candidate holds an RN with 2–3 years of licensed clinical experience, proficient in Microsoft Office, and familiar with utilization management.

Qualifications

• Nursing degree (RN)
• 2-3 years of professional RN experience or equivalent clinical experience
• Strong analytical skills to assess medical claims

Responsibilities

• Review and interpret clinical documentation 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

RN

Analytical skills

Utilization Management experience

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate clinical information and determine payment on member and provider claims according to policies and regulations. The role requires interpreting medical records, applying criteria, and collaborating with clinicians to resolve complex cases.

The ideal candidate holds an RN with 2–3 years of licensed clinical experience, proficient in Microsoft Office, and familiar with utilization management.