RN Claims Review Nurse — Clinical Policy Expert

CVS Health; 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 post-service claims using clinical criteria and regulatory requirements. The role involves reviewing medical documentation, applying decision-making, and coordinating resolutions with clinicians as needed.

It also supports customer service and trains staff, while ensuring compliance with laws and confidentiality. Required RN with 2–3 years of experience, Associates degree (Bachelor's preferred).

Qualifications

• RN required; nursing degree with current licensure.
• 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 utilise 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

Analytical skills

Computer proficiency

Utilization Management experience

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate post-service claims using clinical criteria and regulatory requirements. The role involves reviewing medical documentation, applying decision-making, and coordinating resolutions with clinicians as needed.

It also supports customer service and trains staff, while ensuring compliance with laws and confidentiality. Required RN with 2–3 years of experience, Associates degree (Bachelor's preferred).