Clinical Claim Review Nurse

CVS Health Careers

. Review and interpret clinical documentation from medical records and other systems .

Posted 11/12/2026full-timeRemote • Ohio • United StatesJuniorMid-Level💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical documentation review and evaluation of medical claims, leveraging strong analytical and critical thinking skills. Maintains compliance with applicable laws and regulations while providing clinical support and training to teams.

Highest-signal resume keywords

Active Registered Nurse (RN) LicenseClinical Documentation ReviewAnalytical SkillsMicrosoft Office 365 ProficiencyMedical Claims Evaluation

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical JudgmentPost-Service Claims EvaluationTrend IdentificationFraud DetectionEHR Portal NavigationTechnical Issue ResolutionMultiple Application NavigationSecure System LoginWorkspace SetupInternet Speed Compliance

Soft Skills

Critical ThinkingDigital CommunicationTeam CollaborationTraining SupportIndependent Coordination

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR PortalsVirtual Meeting Platforms

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

Clinical ResolutionsComplianceHIPAA GuidelinesClaims ProcessingMedical Records

About the role

Key responsibilities & impact

Review and interpret clinical documentation from medical records and other systems
Apply clinical judgment, established clinical criteria, and policies to evaluate post-service claims
Coordinate clinical resolutions independently, consulting with clinicians or physicians as needed
Serve as a clinical resource to customer service and claims processing teams
Support training and cross-training of team members
Identify trends, discrepancies, or potential fraud concerns and escalate findings to leadership
Maintain current knowledge of applicable laws, regulations, policies, and workflows to ensure compliance
Support accurate claim determinations

Requirements

What you’ll need

Active, unrestricted Registered Nurse (RN) license
Minimum of 2 years of professional experience as a Registered Nurse (RN) in any clinical setting or specialty area
Strong analytical and critical thinking skills
Ability to review, interpret, and evaluate medical claims and clinical documentation
Associate's or Bachelor's degree in Nursing (RN) from an accredited program
Associate degree in Nursing
Proficiency with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar platforms such as Google Workspace
Strong digital communication skills, including email, Teams messaging, virtual meetings, and calendar management
Ability to set up and use multiple monitors and navigate multiple applications simultaneously
Ability to log in to secure systems such as VPN and EHR portals
Ability to manage strong passwords and recognize suspicious emails or links
Ability to resolve common technical issues independently
Direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 50 Mbps download and 5 Mbps upload
Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Ability to provide workspace furniture, including a desk or standing desk
Ability to obtain required internet speeds and adhere to all Work From Home requirements

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
CVS Health bonus, commission or short-term incentive program eligibility
Company-provided work equipment (keyboard, monitor, computer, headset, etc.)