RN Claims Review Nurse: Clinical Judgment & Compliance

CVS Health Corporation; Michigan; Hybrid; USD 54,000 - 143,000; Full time

Job summary

CVS Health Corporation is hiring a Registered Nurse to review clinical documentation, interpret medical records, and apply clinical criteria to post-service claims. The role requires a nursing degree and an active RN license in the resident state, with 2–3 years of RN experience and strong analytical skills for claims assessment.

This full-time position offers standard benefits and requires 40 hours per week. The pay range and eligibility for CVS Health bonus programs are noted in the posting.

Qualifications

• Active RN license in state of residence.
• RN nursing degree.
• 2–3 years of professional RN experience or equivalent.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to use appropriate 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 compliance.

Skills

RN licensure

Analytical skills

Clinical judgment

Education

Bachelor's degree in Nursing

Job description

CVS Health Corporation is hiring a Registered Nurse to review clinical documentation, interpret medical records, and apply clinical criteria to post-service claims. The role requires a nursing degree and an active RN license in the resident state, with 2–3 years of RN experience and strong analytical skills for claims assessment.

This full-time position offers standard benefits and requires 40 hours per week. The pay range and eligibility for CVS Health bonus programs are noted in the posting.