Clinical Claims Review Nurse
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. 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:
- Registered Nurse License in the state they reside
- 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’s in Science and Nursing
Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/16/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job