RN Clinical Claims Review Specialist

CVS Health Corporation; Kentucky; Hybrid; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health Corporation is seeking an experienced registered nurse to review and interpret clinical documentation for post-service claims from our Kentucky operations. You will apply clinical criteria, coordinate resolutions with clinicians, and support customer service and claims teams to ensure accurate outcomes.

The role requires 2–3 years of RN experience, a Bachelor’s degree, and active licensure in the resident state.

Qualifications

• Active, current and unrestricted RN licensure in state of residence.
• Nursing degree (RN) required.
• 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 needed.
• 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 report discrepancies or potential fraudulent activity to leadership.
• Ensure compliance with applicable laws, regulations, and internal workflows.

Skills

RN licensure

Analytical skills

Education

Bachelor's degree

Job description

CVS Health Corporation is seeking an experienced registered nurse to review and interpret clinical documentation for post-service claims from our Kentucky operations. You will apply clinical criteria, coordinate resolutions with clinicians, and support customer service and claims teams to ensure accurate outcomes.

The role requires 2–3 years of RN experience, a Bachelor’s degree, and active licensure in the resident state.