RN Clinical Claims Review Specialist

CVS Health; Helena (MT); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Comprehensive benefits

Medical coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate documentation and apply clinical criteria to post-service claims. The role requires navigating multiple systems and coordinating resolutions with clinicians as needed.

You will train staff, identify trends, and ensure compliance with state and federal regulations while protecting member confidentiality. The ideal candidate has an RN and 2–3 years of experience and proficiency with Microsoft Office.

Qualifications

• RN required with a nursing license.
• 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

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

Skills

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate documentation and apply clinical criteria to post-service claims. The role requires navigating multiple systems and coordinating resolutions with clinicians as needed.

You will train staff, identify trends, and ensure compliance with state and federal regulations while protecting member confidentiality. The ideal candidate has an RN and 2–3 years of experience and proficiency with Microsoft Office.