[Hiring] Clinical Claim Review Nurse @CVS Health

Role Description

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.
• 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.

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.

Requirements

• 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.

Benefits

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.

Application Deadline

We anticipate the application window for this opening will close on: 11/05/2026.

Equal Opportunity Statement

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.