RN Clinical Claims Review Specialist

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

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Retirement plan

Paid time off

Job summary

CVS Health Corporation is seeking a licensed RN for a full-time role in Oklahoma. The position involves reviewing clinical documentation and applying criteria for post-service claims, coordinating resolutions with clinician support, and serving as a resource for service and claims teams.

The ideal candidate has 2–3 years of RN experience, strong analytical skills, and a Bachelor’s degree. The job includes comprehensive benefits and a 40-hour workweek.

Qualifications

• Must have active current and unrestricted RN licensure in state of residence.
• Bachelor’s degree in nursing (RN).
• Minimum 2–3 years of professional experience as an RN 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 utilize appropriate clinical criteria and policies for 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 existing team members.
• Identify trends and provide feedback to leadership on discrepancies or potential fraud.
• Remain current with laws, regulations, and internal workflows to ensure compliance.

Skills

Analytical skills

Education

Bachelor’s degree

RN licensure

Job description

CVS Health Corporation is seeking a licensed RN for a full-time role in Oklahoma. The position involves reviewing clinical documentation and applying criteria for post-service claims, coordinating resolutions with clinician support, and serving as a resource for service and claims teams.

The ideal candidate has 2–3 years of RN experience, strong analytical skills, and a Bachelor’s degree. The job includes comprehensive benefits and a 40-hour workweek.