RN Clinical Claims Review Specialist

CVS Health

Montana

On-site

USD 36,000 - 77,000

Full time

6 days ago

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Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate clinical information for member and provider claims, applying appropriate criteria and policies. The role involves coordinating resolutions with clinicians and supporting claims processing teams. Candidates should have RN licensure and strong analytical skills.

The position requires a nursing degree with 2–3 years of RN experience, full-time hours, and eligibility for CVS Health bonuses. Comprehensive benefits are provided.

Qualifications

RN nursing degree required.
2-3 years of professional experience as a licensed RN or equivalent.
Strong analytical skills to assess medical claims.

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 support.
Serve as a resource for customer service and claims processing teams.
Train new staff and provide cross-training to team members.
Identify trends and flag discrepancies or potential fraudulent activity.
Ensure compliance with laws, regulations, and internal workflows.

Skills

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Utilization Management

Job description

The position requires a nursing degree with 2–3 years of RN experience, full-time hours, and eligibility for CVS Health bonuses. Comprehensive benefits are provided.

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