RN: Clinical Claim Review & Resolution Specialist

CVS Health; Phoenix (AZ); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Comprehensive benefits

Medical, dental and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in Phoenix is seeking a Clinical Claim Review Nurse to evaluate clinical information and apply policy-based criteria to post-service member and provider claims. You will interpret medical records, coordinate resolutions with clinicians, and ensure compliance with state and federal regulations.

Midlevel responsibilities include serving as a resource for claims teams, training staff, and identifying trends or potential fraud while maintaining confidentiality and quality standards in all

Qualifications

• RN licensure required and current licensure.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

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

Skills

RN

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health in Phoenix is seeking a Clinical Claim Review Nurse to evaluate clinical information and apply policy-based criteria to post-service member and provider claims. You will interpret medical records, coordinate resolutions with clinicians, and ensure compliance with state and federal regulations.

Midlevel responsibilities include serving as a resource for claims teams, training staff, and identifying trends or potential fraud while maintaining confidentiality and quality standards in all