RN Clinical Claims Review Specialist

CVS Health; Columbia (SC); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in the United States. The role involves reviewing and evaluating clinical information and documentation to apply appropriate clinical criteria for post-service claims.

The nurse coordinates resolutions with clinicians and supports customer service and claims processing teams. Required RN license and 2–3 years of clinical experience; Associates degree required with BSN preferred.

Qualifications

• RN license (state-allowed)
• 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 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

Analytical skills

Clinical judgment

RN experience

Education

Associates Degree in Nursing

BSN preferred

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse in the United States. The role involves reviewing and evaluating clinical information and documentation to apply appropriate clinical criteria for post-service claims.

The nurse coordinates resolutions with clinicians and supports customer service and claims processing teams. Required RN license and 2–3 years of clinical experience; Associates degree required with BSN preferred.