Impactful RN: Clinical Claims Reviewer

CVS Health; Virginia Beach (VA); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Retirement options

Job summary

CVS Health in Virginia Beach seeks a Clinical Claim Review Nurse to evaluate clinical information and documentation for member and provider claims, applying clinical criteria and policies while ensuring compliance with regulatory requirements. You will coordinate clinical resolution with clinicians as needed, and protect member confidentiality.

The role requires interpreting medical records, supporting claims processing teams, training staff, and identifying trends to improve accuracy and

Qualifications

• RN license required
• 2–3 years RN experience preferred
• Strong analytical skills for medical claims and documentation

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria to post-service claims per policies and regulations.
• Coordinate clinical resolutions with clinician/MD support.
• Serve as resource for customer service and claims processing teams.
• Train new staff and provide cross-training.
• Identify trends and report potential discrepancies or fraudulent activities.
• Stay current with laws, regulations and internal workflows.

Skills

RN

Clinical claims analysis

Regulatory compliance

Education

Associates Degree in Nursing

BSN preferred

Tools

Microsoft Office

Electronic Health Records

Job description

CVS Health in Virginia Beach seeks a Clinical Claim Review Nurse to evaluate clinical information and documentation for member and provider claims, applying clinical criteria and policies while ensuring compliance with regulatory requirements. You will coordinate clinical resolution with clinicians as needed, and protect member confidentiality.

The role requires interpreting medical records, supporting claims processing teams, training staff, and identifying trends to improve accuracy and