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Clinical Claim Review Nurse
CVS Health. Review and interpret clinical documentation from medical records and other systems .
Core Competencies
Role fitCore 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 ReviewMedical Claims EvaluationMicrosoft Office 365 ProficiencyAnalytical And Critical Thinking Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical JudgmentTrend IdentificationFraud DetectionEHR Portal NavigationTechnical Troubleshooting
Soft Skills
Digital Communication SkillsTeam CollaborationTraining And Cross-Training
Tools & Technologies
Microsoft Office 365Google WorkspaceVPN Access
Certifications & Qualifications
Registered Nurse (RN) License
Industry Keywords
HIPAA ComplianceClinical CriteriaClaims ProcessingHealthcare Regulations
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 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
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
- 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
- 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 workspace compliant with CVS Health and HIPAA guidelines
- Ability to work within the state and city where currently living
- Ability to use multiple monitors and navigate multiple applications
- 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 troubleshoot common technical issues
- Openness to learning new skills as the workplace environment evolves
Benefits
Comp & perks- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
- Medical, dental, and 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 in addition to base pay