RN Clinical Claims Reviewer

CVS Health

Kentucky

On-site

USD 36,000 - 77,000

Full time

6 days ago

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Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in Kentucky to review and evaluate clinical information for member and provider claims. The role requires RN licensure, 2–3 years of experience, and strong analytical skills to assess medical claims.

You will coordinate resolutions with clinicians and support teams, train staff, and stay compliant with laws and policies. The position is full-time, 40 hours weekly, with benefits including medical, dental, and vision coverage, paid time off,

Qualifications

RN license and nursing degree.
2–3 years of professional RN experience or equivalent.
Strong analytical skills to assess medical claims.

Responsibilities

Review and interpret clinical documentation from medical records or systems.
Apply clinical criteria and policies for post-service claims.
Coordinate clinical resolutions 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 on discrepancies or potential fraud.
Remain current with applicable laws, regulations, and internal workflows to ensure compliance.