RN Clinical Claims Reviewer: Impact & Insight

CVS Health Corporation; Ohio; Hybrid; USD 74,530,000 - 196,424,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Job summary

CVS Health Corporation is seeking a Registered Nurse to review clinical documentation, apply decision criteria for post-service claims, and coordinate resolutions with clinical support as needed. The role supports customer service and claims teams, with opportunities to train staff and identify trends for leadership review.

A strong adherence to regulations and internal workflows is essential. Requires active RN licensure, RN degree, and 2-3 years of professional RN experience.

Qualifications

• 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 claim 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 provide leadership feedback on discrepancies or potential fraud.
• Stay current with laws, regulations and internal workflows to ensure compliance.

Skills

Analytical skills

Education

RN licensure

Bachelor's degree

Job description

CVS Health Corporation is seeking a Registered Nurse to review clinical documentation, apply decision criteria for post-service claims, and coordinate resolutions with clinical support as needed. The role supports customer service and claims teams, with opportunities to train staff and identify trends for leadership review.

A strong adherence to regulations and internal workflows is essential. Requires active RN licensure, RN degree, and 2-3 years of professional RN experience.