RN Clinical Claims Review Specialist

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

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to assess post-service medical claims by interpreting clinical documentation and applying established criteria. The role supports coordination with clinicians and claims teams, trains staff, and monitors trends for quality and compliance.

The position requires an RN with 2–3 years of experience, an Associates degree in Nursing (BSN preferred), and proficiency with Microsoft Office; typical weekly hours are 40, with full-time employment in

Qualifications

• RN license with 2–3 years of clinical experience.
• Strong analytical skills to assess medical claims.
• Associates Degree in Nursing required; BSN preferred.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies to 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 team members.
• Identify trends and report discrepancies or potential fraud to leadership.
• Stay current with laws, regulations, and internal workflows to ensure compliance.

Skills

Analytical skills

Communication skills

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 assess post-service medical claims by interpreting clinical documentation and applying established criteria. The role supports coordination with clinicians and claims teams, trains staff, and monitors trends for quality and compliance.

The position requires an RN with 2–3 years of experience, an Associates degree in Nursing (BSN preferred), and proficiency with Microsoft Office; typical weekly hours are 40, with full-time employment in