Clinical Claims Review Nurse

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, reputed company 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 reputed company 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 reputed company cross-training to existing team members
• Identify trends and reputed company feedback to leadership if discrepancies or potential fraudulent activities are identified
• Remain reputed company 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 reputed company
• 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, reputed company 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 reputed company The typical pay reputed company for this role is: $29.10 - $62.32 This pay reputed company represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay reputed company 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 reputed company 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 reputed company 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 reputed company on: 03/16/2026 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply tot his job Apply To this Job