RN Clinical Claims Reviewer — Post-Service & Compliance

CVS Health; Philadelphia (Philadelphia County); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Comprehensive benefits package

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in the United States to evaluate clinical documentation and apply appropriate criteria to post-service claims. You will coordinate resolutions with clinicians, support customer service and claims teams, and train staff while ensuring compliance with regulatory requirements.

The role emphasizes confidentiality, accuracy, and ongoing awareness of state and federal regulations.

Qualifications

• RN with nursing degree and active RN license.
• 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation for post-service claims.
• Apply clinical criteria and policies to claim reviews.
• Coordinate clinical resolutions independently with clinician/MD support.
• Serve as a resource for customer service and claims teams.
• Train new staff and cross-train existing team members.
• Identify trends and report discrepancies or potential fraud.
• Ensure compliance with laws, regulations and workflows.

Skills

Analytical skills

RN licensed

Utilization Management experience

Microsoft Office

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse in the United States to evaluate clinical documentation and apply appropriate criteria to post-service claims. You will coordinate resolutions with clinicians, support customer service and claims teams, and train staff while ensuring compliance with regulatory requirements.

The role emphasizes confidentiality, accuracy, and ongoing awareness of state and federal regulations.