RN Clinical Claims Reviewer

CVS Health; Sacramento (CA); On-site; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate clinical information and documentation for member and provider claims. You will interpret records, apply clinical criteria, and work with clinicians to resolve post-service claims while ensuring compliance with state and federal regulations.

You will also support customer service teams and participate in training of staff. The role requires a nursing degree (RN) and 2–3 years of RN experience, with strong analytical skills and

Qualifications

• Nursing degree (RN)
• 2–3 years of professional experience as a licensed RN 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 to post-service claims.
• Coordinate clinical resolutions independently with clinician/MD support as needed.
• Serve as a resource for customer service and claims processing teams.
• Train new staff and cross-train existing team members.
• Identify trends and provide feedback to leadership on discrepancies or potential fraud.
• Stay current with applicable laws, regulations, and internal workflows to ensure compliance.

Skills

RN license

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate clinical information and documentation for member and provider claims. You will interpret records, apply clinical criteria, and work with clinicians to resolve post-service claims while ensuring compliance with state and federal regulations.

You will also support customer service teams and participate in training of staff. The role requires a nursing degree (RN) and 2–3 years of RN experience, with strong analytical skills and