RN Clinical Claims Reviewer & Policy Expert

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

Benefits offered by this job

Bonus program

Commission eligibility

Short-term incentive program

Job summary

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate medical documentation and apply clinical criteria to post-service claims, ensuring accuracy and regulatory compliance. You will navigate multiple systems, coordinate with clinicians, and serve as a resource for claims processing teams.

The role offers full-time hours, competitive benefits, and eligibility for CVS Health bonus programs, with opportunities for professional development and impact across patient

Qualifications

• RN with 2–3 years of professional experience as a licensed Registered Nurse (RN)
• Strong analytical skills to assess medical claims
• Computer proficiency, Microsoft Suite
• Utilization Management experience preferred

Responsibilities

• Review and interpret clinical documentation and apply criteria and policies for member/provider claims
• Coordinate clinical resolution with clinicians/MDs as required
• Evaluate post-service claims for payment per policies, regulations, and plan benefits
• Navigate multiple system applications and liaise with internal departments or providers as needed
• Adhere to confidentiality and company policies; ensure compliance with laws and regulations
• Train new staff and provide cross-training to teammates
• Identify trends and report discrepancies or potential fraudulent activity to leadership

Skills

Analytical skills

RN experience

Education

Associates Degree in Nursing

BSN preferred

Tools

Microsoft Office

Job description

CVS Health in the United States is seeking a Clinical Claim Review Nurse to evaluate medical documentation and apply clinical criteria to post-service claims, ensuring accuracy and regulatory compliance. You will navigate multiple systems, coordinate with clinicians, and serve as a resource for claims processing teams.

The role offers full-time hours, competitive benefits, and eligibility for CVS Health bonus programs, with opportunities for professional development and impact across patient