RN — Clinical Claims Review Specialist

CVS Health; South Carolina; Hybrid; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement plan

Wellness programs

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate post‑service claims using clinical criteria and regulatory requirements. The role involves reviewing medical records, coordinating with clinicians, and ensuring confidentiality across multiple systems.

Qualified candidates hold an RN license with 2–3 years of experience and strong analytical skills to interpret documentation and apply appropriate policies. Benefits include comprehensive medical coverage and retirement options.

Qualifications

• RN license held as required.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess clinical documentation and claims.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to post‑service claims using appropriate criteria and policies.
• Coordinate resolutions with clinician/MD support as needed.
• Serve as a resource for customer service and claims processing teams.
• Train new staff and cross-train to existing team members.
• Identify trends and report potential discrepancies or fraud to leadership.

Skills

RN

Clinical analysis

Regulatory compliance

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate post‑service claims using clinical criteria and regulatory requirements. The role involves reviewing medical records, coordinating with clinicians, and ensuring confidentiality across multiple systems.

Qualified candidates hold an RN license with 2–3 years of experience and strong analytical skills to interpret documentation and apply appropriate policies. Benefits include comprehensive medical coverage and retirement options.