RN Clinical Claims Reviewer - Post-Service Expert

CVS Health; Clayton (NM); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Clinical Claim Review Nurse to evaluate medical records and apply clinical criteria to post-service claims. The role involves reviewing documentation, coordinating with clinicians, and ensuring compliance with regulatory requirements.

The position requires an RN license, an Associates degree in Nursing (BSN preferred), 2–3 years of RN experience, and strong analytical skills. This is a full-time role with a comprehensive benefits package.

Qualifications

• Nursing degree (RN).
• Minimum of 2-3 years of professional experience as a licensed RN.
• Strong analytical skills to assess medical claims.
• Associates Degree in Nursing required; Bachelor’s degree preferred.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to utilize appropriate criteria for post-service claims.
• Coordinate clinical resolutions independently, with clinician support as required.
• Act 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 fraud.
• Stay current with laws, regulations, and internal workflows to ensure compliance.

Skills

Analytical skills

Utilization Management experience

Computer proficiency

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse to evaluate medical records and apply clinical criteria to post-service claims. The role involves reviewing documentation, coordinating with clinicians, and ensuring compliance with regulatory requirements.

The position requires an RN license, an Associates degree in Nursing (BSN preferred), 2–3 years of RN experience, and strong analytical skills. This is a full-time role with a comprehensive benefits package.