Clinical Claims Review Nurse

CVS Health

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

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

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation review, applying clinical decision-making for claims processing, and ensuring compliance with laws and regulations. Proficient in training staff and identifying trends in clinical resolutions.

Highest-signal resume keywords

Registered Nurse LicensureClinical Documentation ReviewClaims ProcessingAnalytical SkillsCompliance with Regulations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Decision-MakingMedical Claims AssessmentTrend IdentificationClinical Criteria ApplicationTraining and Cross-Training

Soft Skills

ResourcefulnessCommunicationProblem-Solving

Certifications & Qualifications

Registered Nurse Licensure

Industry Keywords

Clinical DocumentationPost-Service ClaimsFraudulent ActivitiesInternal WorkflowsNursing Degree

About the role

Key responsibilities & impact

Review and interpret clinical documentation obtained 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 provide cross-training to 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 remain current with applicable laws, regulations, and internal workflows
Ability to comply with organizational 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 in addition to base pay