RN Clinical Claims Review Specialist

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

Job summary

CVS Health Corporation is seeking a full-time RN to review and interpret clinical documentation from medical records and systems. The role involves applying clinical criteria to post-service claims and coordinating resolutions with clinical support as needed.

The position requires an active RN license in the resident state, a nursing degree, and 2–3 years of professional RN experience. Strong analytical skills to assess medical claims are essential.

Qualifications

• Must have active current and unrestricted RN licensure in state of residence.
• Nursing degree (RN).
• A minimum of 2-3 years of professional experience as an RN or equivalent.
• 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 if discrepancies or potential fraudulent activities are identified.
• Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements.

Skills

Analytical skills

Clinical judgment

Communication

Education

RN licensure in state of residence

Bachelor's degree

Job description

CVS Health Corporation is seeking a full-time RN to review and interpret clinical documentation from medical records and systems. The role involves applying clinical criteria to post-service claims and coordinating resolutions with clinical support as needed.

The position requires an active RN license in the resident state, a nursing degree, and 2–3 years of professional RN experience. Strong analytical skills to assess medical claims are essential.