RN Clinical Claims Reviewer

CVS Health; Saint Paul (MN); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Bonus eligibility

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in Minnesota to review and evaluate clinical information for member and provider claims. You will apply clinical criteria, coordinate resolutions with clinicians, and support claims processing while ensuring confidentiality and regulatory compliance.

The role emphasizes independence, collaboration with healthcare teams, and staying current with laws and internal policies. Full-time, 40 hours weekly, with CVS Health bonus eligibility.

Qualifications

• RN licensed; 2–3 years of professional clinical experience.
• Strong analytical skills to assess medical 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 clinical resolutions independently, with clinician/MD support as needed.
• 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 alert leadership to discrepancies or potential fraud.
• Stay current with applicable laws, regulations, and internal workflows to ensure compliance.

Skills

RN licensed

Analytical skills

Utilization Management

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse in Minnesota to review and evaluate clinical information for member and provider claims. You will apply clinical criteria, coordinate resolutions with clinicians, and support claims processing while ensuring confidentiality and regulatory compliance.

The role emphasizes independence, collaboration with healthcare teams, and staying current with laws and internal policies. Full-time, 40 hours weekly, with CVS Health bonus eligibility.