RN Clinical Claims Review Specialist

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

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Benefits package for colleagues and/or

Wellness programs

Job summary

CVS Health is hiring a registered nurse reviewer to exercise clinical judgment in evaluating medical records and post-service claims. This full-time role in Utah involves analyzing relevant documentation, applying criteria, coordinating resolutions with clinicians, and supporting customer service and claims teams.

Requires active RN licensure, a RN degree, and 2–3 years of RN experience. Competitive benefits and a pay range reflected in the listing.

Qualifications

• Must hold active, unrestricted RN licensure in the resident state.
• Nursing degree (RN) required.
• Minimum 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation from medical records/systems.
• Apply clinical criteria for post-service claims to guide decisions.
• Coordinate clinical resolutions independently with clinician/MD support.
• Serve as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training to existing team members.
• Identify trends and report discrepancies or potential fraudulent activities to leadership.
• Ensure compliance with applicable laws, regulations, and internal workflows.

Skills

RN licensure

RN degree

2-3 yrs experience

Analytical skills

Education

Bachelor's degree

Job description

CVS Health is hiring a registered nurse reviewer to exercise clinical judgment in evaluating medical records and post-service claims. This full-time role in Utah involves analyzing relevant documentation, applying criteria, coordinating resolutions with clinicians, and supporting customer service and claims teams.

Requires active RN licensure, a RN degree, and 2–3 years of RN experience. Competitive benefits and a pay range reflected in the listing.