RN Clinical Claims Review Specialist

CVS Health; Santa Fe (NM); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Comprehensive benefits

Bonus program

Paid time off

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to assess post-service claims by reviewing clinical records and applying appropriate criteria. You will coordinate with clinicians to resolve complex cases, support claims teams with clinical guidance, and train staff while staying compliant with laws and policies.

Ideal candidates hold an RN license with 2–3 years of experience and strong analytical skills.

Qualifications

• RN with nursing degree and license.
• 2–3 years of RN experience required.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and evaluate clinical documentation for post-service claims.
• Coordinate clinical resolutions with clinicians/MD as needed.
• Support claims processing teams with clinical guidance.
• Train new staff and cross-train existing team members.
• Identify trends or potential fraud and report to leadership.

Skills

RN

Analytical skills

2-3 years experience

Education

Associates Degree in Nursing

BSN preferred

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse to assess post-service claims by reviewing clinical records and applying appropriate criteria. You will coordinate with clinicians to resolve complex cases, support claims teams with clinical guidance, and train staff while staying compliant with laws and policies.

Ideal candidates hold an RN license with 2–3 years of experience and strong analytical skills.