RN Clinical Claims Reviewer — Analyze & Resolve Post-Service Claims

CVS Health; Beryl (WV); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health in the United States seeks a Clinical Claim Review Nurse to review and evaluate clinical information for member and provider claims, applying clinical criteria and policies in line with regulatory requirements. The role coordinates clinical resolution with clinician support as needed, and ensures confidentiality and compliance.

The ideal candidate is an RN with 2–3 years of professional experience, strong analytical skills, and proficiency in Microsoft Office.

Qualifications

• RN license is required as part of nursing qualifications.
• 2–3 years of professional RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.
• Proficiency with Microsoft Office tools.
• Familiarity with Utilization Management concepts is a plus.

Responsibilities

• Review and interpret clinical documentation from medical records and systems.
• Apply clinical criteria and policies to post-service claims.
• Coordinate clinical resolutions independently with clinician support as needed.
• Act as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training to team members.
• Identify trends and report discrepancies or potential fraud to leadership.
• Ensure compliance with laws, regulations and internal workflows.

Skills

Analytical skills

Education

RN license

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health in the United States seeks a Clinical Claim Review Nurse to review and evaluate clinical information for member and provider claims, applying clinical criteria and policies in line with regulatory requirements. The role coordinates clinical resolution with clinician support as needed, and ensures confidentiality and compliance.

The ideal candidate is an RN with 2–3 years of professional experience, strong analytical skills, and proficiency in Microsoft Office.