RN: Clinical Claims Review Specialist (Full-Time)

CVS Health; Philadelphia (Philadelphia County); On-site; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in Philadelphia to evaluate and interpret clinical documentation for post-service claims. The role involves applying clinical criteria in line with regulations and plan benefits, coordinating resolutions with clinicians, and assisting customer service and claims teams.

The position requires an RN with 2–3 years of professional experience, strong analytical skills, and familiarity with MS Office.

Qualifications

• Licensed RN with 2–3 years of professional nursing experience.
• Strong analytical skills to assess medical claims and documentation accuracy.
• Familiarity with clinical criteria, policies, and regulatory requirements.

Responsibilities

• Review and interpret clinical documentation from medical records to determine claim outcomes.
• Apply clinical criteria and policies to post-service claims.
• Coordinate resolutions with clinicians/MDs as needed and communicate with care teams.
• Serve as a resource for customer service and claims processing teams.
• Assist in training staff and share cross-training across the team.
• Identify trends or potential fraud, and report to leadership.
• Stay updated on laws, regulations and internal workflows to ensure compliance.

Skills

RN license

Analytical skills

Clinical decision making

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

CVS Health is seeking a Clinical Claim Review Nurse in Philadelphia to evaluate and interpret clinical documentation for post-service claims. The role involves applying clinical criteria in line with regulations and plan benefits, coordinating resolutions with clinicians, and assisting customer service and claims teams.

The position requires an RN with 2–3 years of professional experience, strong analytical skills, and familiarity with MS Office.