RN Claims Review Nurse | Clinical Policy Expert

CVS Health; Charleston (WV); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision

401(k) plan

Paid time off

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate post-service claims using clinical policies and regulations. The role requires RN licensure, 2–3 years of nursing experience, and strong analytical skills.

You will coordinate resolutions with clinicians and support teams, train staff, and help ensure compliant, accurate claim processing. The position is full-time in the United States with a comprehensive benefits package including health coverage and retirement options.

Qualifications

• RN licensure and active nursing degree.
• 2–3 years of professional RN experience.
• Strong analytical skills for medical claims.
• Experience with utilization management preferred.

Responsibilities

• Review and interpret clinical documentation from medical records and systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions independently with clinician/MD support.
• Serve as a resource for customer service and claims teams.
• Train new staff and cross-train existing team members.
• Identify trends and report discrepancies or fraud indicators.
• Stay current with laws, regulations, and internal workflows.

Skills

RN licensure

Analytical skills

Clinical decision making

Communication

Education

Associate's Degree in Nursing

BSN preferred

Tools

Microsoft Office

Utilization Management systems

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate post-service claims using clinical policies and regulations. The role requires RN licensure, 2–3 years of nursing experience, and strong analytical skills.

You will coordinate resolutions with clinicians and support teams, train staff, and help ensure compliant, accurate claim processing. The position is full-time in the United States with a comprehensive benefits package including health coverage and retirement options.