RN Clinical Claims Reviewer

CVS Health; Wisconsin; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision coverage

Paid time off

Retirement plan

Job summary

CVS Health seeks a Clinical Claim Review Nurse to evaluate clinical information and documentation for post-service claims using established policies. You will interpret data from medical records, applying clinical criteria to determine coverage decisions.

The role requires RN licensure, 2–3 years of relevant experience, and strong analytical skills to support claims processing and customer service teams. This is a full-time, on-site position in Wisconsin with comprehensive benefits.

Qualifications

• RN with active license.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review clinical information and apply appropriate criteria and policies for member and/or provider claims.
• Coordinate clinical resolutions with clinicians/MDs as required.
• Ensure reviews comply with laws, regulations, and plan benefits; protect confidentiality.

Skills

RN

Experience 2-3 years

Analytical skills

Education

Associate's Degree in Nursing

BSN preferred

Tools

Microsoft Suite

Job description

CVS Health seeks a Clinical Claim Review Nurse to evaluate clinical information and documentation for post-service claims using established policies. You will interpret data from medical records, applying clinical criteria to determine coverage decisions.

The role requires RN licensure, 2–3 years of relevant experience, and strong analytical skills to support claims processing and customer service teams. This is a full-time, on-site position in Wisconsin with comprehensive benefits.