Impactful RN: Clinical Claims Reviewer

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

Benefits offered by this job

Medical, Dental, Vision

Paid time off

Retirement savings options

Wellness programs

Eligibility-based resources

Job summary

CVS Health is hiring a Clinical Claim Review Nurse to evaluate clinical information for member and provider claims. The role requires RN licensure, 2–3 years of clinical experience, and strong analytical skills to assess medical claims.

You will interpret documentation, apply clinical criteria, and coordinate resolutions with clinicians as needed. This full-time position offers benefits including medical, dental, and vision coverage, PTO, retirement plans, wellness programs, and

Qualifications

• RN nursing degree and license.
• 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 criteria and policies to 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 team members.
• Identify trends and feedback to leadership on discrepancies or potential fraud.
• Maintain compliance with laws, regulations and internal workflows.

Skills

Analytical skills

Computer proficiency

Utilization Management experience

Education

Associate Degree in Nursing

Bachelor of Science in Nursing (BSN) preferred

Tools

Microsoft Office

Job description

CVS Health is hiring a Clinical Claim Review Nurse to evaluate clinical information for member and provider claims. The role requires RN licensure, 2–3 years of clinical experience, and strong analytical skills to assess medical claims.

You will interpret documentation, apply clinical criteria, and coordinate resolutions with clinicians as needed. This full-time position offers benefits including medical, dental, and vision coverage, PTO, retirement plans, wellness programs, and