We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.
As a Clinical Claim Review Nurse you will be responsible for the review and evaluation of clinical information and documentation.
Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims.
Independently coordinates the clinical resolution with clinician/MD support as required.
Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits.
Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers.
Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations.
Adhere to company policies regarding confidentiality to protect member information.
This role requires the nurse to exercise clinical judgment and perform the following duties:
- Review and interpret clinical documentation obtained from medical records or systems.
- Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims
- Coordinate clinical resolutions independently, with clinician/MD 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 feedback to leadership if discrepancies or potential fraudulent activities are identified
- Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements
Required Qualifications:
- Nursing degree (RN)
- A minimum of 2-3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience
- Strong analytical skills to assess medical claims
Preferred Qualifications
- Computer proficiency, Microsoft Suite
- Utilization Management experience
Education
- Associates Degree in Nursing required
- Bachelor of Science and Nursing preferred
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$26.01 - $56.14
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 11/05/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills:
Analysis Skills, Claims Processing, Clinical Data, Clinical Information, Clinical Information Systems, Clinical Medicine, Clinical Nursing, Clinical Study Publications, Computer Skills, Corporate Policies, Cross-Training, Customer Support/Service, Documentation, Documentation Review, Establish Priorities, Federal Laws and Regulations, Geography, Healthcare, Incentive Programs, Information/Data Security (InfoSec), Leadership, Medical Record System, Medical Records, Microsoft Product Family, Nursing, Registered Nurse (RN), Regulations, Regulatory Requirements, Safety/Work Safety, Staff Training, State Laws and Regulations, Systems Analysis, Trend Analysis, Utilization Management
CVS Health Corp
CVS Health offers a world of promising job opportunities across a diverse range of careers in everything from corporate and pharmacy roles to retails positions. No matter where you work at CVS Health, your unique skills, talents and abilities are welcome and valued. We recognize and reward greatness and want our employees to know their work is making a difference in the lives of millions. Join us today. Together we can continue making innovative, high-quality health and pharmacy services safe, affordable and accessible – for all.
Company Size:
10,000 employees or more
Industry:
Biotechnology/Pharmaceuticals
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