Clinical Claims Review Nurse

CVS Health

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

Posted 10/8/2026full-timeRemote • North Dakota • United StatesJuniorMid-Level💰 $26 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation review, clinical decision-making, and compliance with laws and regulations. Proficient in training staff and identifying trends in medical claims to support operational efficiency.

Highest-signal resume keywords

Registered Nurse LicensureClinical Decision-MakingAnalytical SkillsTraining and DevelopmentCompliance with Regulations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewMedical Claims AssessmentPost-Service Claims ProcessingTrend IdentificationFraud Detection

Soft Skills

ResourcefulnessCommunication SkillsTeam Collaboration

Certifications & Qualifications

Registered Nurse License

Industry Keywords

Clinical CriteriaHealthcare ComplianceMedical RecordsClaims ProcessingNursing Degree

About the role

Key responsibilities & impact

Review and interpret clinical documentation from medical records or systems
Apply clinical decision-making and 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 cross-train existing team members
Identify trends and provide feedback to leadership regarding discrepancies or potential fraudulent activities
Remain current with applicable laws, regulations, and internal workflows to ensure compliance

Requirements

What you’ll need

Active, current and unrestricted Registered Nurse licensure in state of residence
Nursing degree (RN)
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
Bachelor's degree
Ability to comply with applicable laws, regulations, internal workflows, and state-specific 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