RN Clinical Claims Review Specialist

CVS Health; Illinois; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Bonus eligible

Comprehensive benefits

Job summary

CVS Health in the United States seeks a Clinical Claim Review Nurse to review and evaluate clinical information and documentation to determine claim payment decisions.

Responsibilities include interpreting records, applying clinical criteria and policies, coordinating with clinicians, and ensuring compliance with state and federal laws. This full-time role includes a comprehensive benefits package and eligibility for a bonus.

Qualifications

• Licensed RN with current nursing license.
• 2–3 years professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Reviews documentation and interprets data from clinical records to apply clinical criteria.
• Independently coordinates clinical resolution with clinician/MD support.
• Reviews post-service claims for payment based on policies and regulatory requirements.
• Navigate multiple system applications and outreach to internal departments as needed.
• Apply review requirements to ensure compliance with policies and laws.
• Remain current with applicable regulations and internal workflows.

Skills

RN Nursing

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing preferred

Tools

Microsoft Office Suite

Job description

CVS Health in the United States seeks a Clinical Claim Review Nurse to review and evaluate clinical information and documentation to determine claim payment decisions.

Responsibilities include interpreting records, applying clinical criteria and policies, coordinating with clinicians, and ensuring compliance with state and federal laws. This full-time role includes a comprehensive benefits package and eligibility for a bonus.