RN Clinical Claims Reviewer: Post‑Service Claims

CVS Health

Tallahassee (FL)

On-site

USD 36,000 - 77,000

Full time

5 days ago

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Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is hiring a Clinical Claim Review Nurse in the United States. The role involves reviewing clinical information and applying policies to post-service claims, coordinating resolutions with clinicians, and supporting claims processing teams.

The position requires an RN license, an Associate degree (BSN preferred), and 2–3 years of clinical experience with strong analytical skills. Full-time hours, comprehensive benefits, and opportunities for ongoing training are available.

Qualifications

RN license and nursing degree required.
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 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 report discrepancies or potential fraud to leadership.
Stay current with laws, regulations, and internal workflows to ensure compliance.