We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate 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.

As a Clinical Claim Review Nurse you will be responsible for the review and evaluation of clinical information and documentation. 
Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. 
Independently coordinates the clinical resolution with clinician/MD support as required. 
Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits. 
Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers. 
Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations. 
Adhere to company policies regarding confidentiality to protect member information.

Required Qualifications

5+ years of clinical experience required2+ years of experience as a Registered NurseMust have active, current and unrestricted RN licensure in state of residence1+ years of experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews.

Preferred Qualifications

Managed Care experience

Education

Associates Degree in Nursing requiredBachelor of Science and Nursing preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range 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 all 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 access 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 close on: 02/02/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.