RN Clinical Claims Review Specialist

CVS Health; Juneau (AK); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision 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 post-service claims by reviewing clinical documentation and applying appropriate criteria and policies. The role requires an RN with 2–3 years of professional experience and strong analytical skills to ensure accurate, compliant determinations.

The position supports customer service and claims processing teams, trains new staff, and coordinates resolutions with clinicians.

Qualifications

• RN required with 2–3 years of professional experience.
• Strong analytical skills to assess medical claims.
• Familiarity with utilization management is preferred.

Responsibilities

• Review and interpret clinical documentation from medical records and systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions independently with clinician/MD support as needed.
• Serve as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training.
• Identify trends and flag discrepancies or potential fraud.
• Stay current with applicable laws, regulations, and internal workflows.

Skills

Analytical skills

Utilization Management experience

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate post-service claims by reviewing clinical documentation and applying appropriate criteria and policies. The role requires an RN with 2–3 years of professional experience and strong analytical skills to ensure accurate, compliant determinations.

The position supports customer service and claims processing teams, trains new staff, and coordinates resolutions with clinicians.