RN Clinical Claims Reviewer | Impactful Health Policy

CVS Health; Austin (TX); 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 to evaluate medical documentation and apply clinical criteria for post-service claims. You will coordinate resolutions with clinicians and support teams, ensuring compliance with regulations and plan benefits.

The role requires an RN license and 2–3 years of related experience, with strong analytical skills and familiarity with Microsoft Office. This is a full-time, on-site position in Austin, TX, with comprehensive benefits.

Qualifications

• RN required for professional licensure.
• 2–3 years of RN experience or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies for post-service claims.
• Coordinate clinical resolutions with clinician/MD support as required.
• Assist customer service and claims processing teams as a resource.
• Train new staff and cross-train team members.
• Identify trends and report discrepancies or potential fraud.

Skills

RN license

Clinical data interpretation

Analytical skills

Regulatory awareness

Education

Associates Degree in Nursing

BSN preferred

Tools

Microsoft Office

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate medical documentation and apply clinical criteria for post-service claims. You will coordinate resolutions with clinicians and support teams, ensuring compliance with regulations and plan benefits.

The role requires an RN license and 2–3 years of related experience, with strong analytical skills and familiarity with Microsoft Office. This is a full-time, on-site position in Austin, TX, with comprehensive benefits.