RN Clinical Claims Reviewer

CVS Health Corporation; Texas; Hybrid; USD 36,000 - 95,000; Full time

Job summary

CVS Health Corporation in the United States is seeking a Registered Nurse to review clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinical support as needed.

The role includes training staff, identifying trends, and ensuring compliance with laws and internal workflows. Strong analytical skills and nursing qualifications are essential for success.

Qualifications

• Must have active current and unrestricted Registered Nurse licensure in state of residence.
• Nursing degree (RN)
• A minimum of 2-3 years of professional experience as a licensed RN, or equivalent

Responsibilities

• Review and interpret clinical documentation obtained from medical records or systems.
• Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims
• Coordinate clinical resolutions independently, 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 if discrepancies or potential fraudulent activities are identified
• Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state‑specific requirements

Skills

Analytical skills

Clinical decision-making

Education

Bachelor's degree in Nursing

Job description

CVS Health Corporation in the United States is seeking a Registered Nurse to review clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinical support as needed.

The role includes training staff, identifying trends, and ensuring compliance with laws and internal workflows. Strong analytical skills and nursing qualifications are essential for success.