Clinical Claims Review Nurse
$26.01 - $68.55 per hourCVS
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 ourselvesaccountable 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. This role requires the nurse to exercise clinical judgment and perform the following duties: Review and interpret clinical documentation obtained from medical records or systems. Apply clinical decision-making to utilize 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 if discrepancies or potential fraudulent activities are identified Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements Required Qualifications: Must have active current and unrestricted Registered Nurse licensure in state of residence Nursing degree (RN) A 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 Education: Bachelor's degree Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $68.55 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 10/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr
$69.3k - $78k
A healthcare payment integrity company is seeking a Medical Review Nurse II - Clinical Validation to perform medical claims audits for Government and Commercial Payers. The position requires an active RN license and a minimum of five years nursing experience. Responsibilities...ClaimsRemote job- Elevance Health in Harrisburg, PA seeks a Clinical Review Nurse I to assess the necessity and reasonableness of items in claims and to adjudicate them using medical policy. The role requires clinical experience and an active RN license in the United States, with a Monday...ClaimsFull timeMonday to Friday
$70k - $95k
...We are seeking a remote Clinical Claims Review RN to join an established and growing clinical review team. In this role, you will combine acute... ...is fully remote. This role is well suited for a registered nurse with a strong ICU, emergency, or operating room foundation who...ClaimsHourly payFull timeWork at officeLocal areaRemote workMonday to FridayTalentLNX LLC
New York, NY3 days ago- ...About This Role The Clinical Review Nurse I is responsible for reviewing and making medical determinations regarding claims to ensure they meet the benefits carried by members. This role is ideal for individuals seeking a flexible, virtual work environment while contributing...ClaimsFull timeTemporary workFlexible hours
Elevance Health
New York, NY2 days ago - Elevance Health is seeking a Clinical Review Nurse I to review and make medical determinations on claims to ensure members receive the benefits described in their plans in a flexible, virtual environment. The role emphasizes assessing the necessity and reasonableness of...ClaimsRemote jobFlexible hours
$26.01 - $68.55 per hour
...one community at a time. This role requires the nurse to exercise clinical judgment and perform the following duties: Review and interpret clinical documentation obtained... ...criteria and policies for post-service claims Coordinate clinical resolutions independently,...ClaimsHourly payFull timeTemporary workLocal area$31 - $35 per hour
Clinical Review & Correspondence RN The Clinical Review & Correspondence RN plays a critical role... ...assigned What you'll need: Registered Nurse with active, unencumbered license in the... ...service authorization data with post-service claims validation, we're creating a transparent...ClaimsFull timeRemote workFlexible hoursShift work$69.3k - $78k
Overview Medical Review Nurse II - Clinical Validation At Performant, we’re focused on helping our clients achieve their goals by providing technology... ...Nurse II - Clinical Validation primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of...ClaimsFor contractorsWork at officeRemote workWork from homeHome officeShift work- ...leading healthcare intelligence company. The Medical Review Nurse II audits home health claims, working remotely with a multi-location team to ensure... ...high-quality documentation. The role emphasizes strong clinical judgment, coding accuracy, and regulatory awareness. You...ClaimsRemote jobWork from home
- Sedgwick, a global leader in claims management, seeks an Accommodation Clinical Specialist to perform standard clinical evaluations on claims needing additional review and to consult with providers and employees to substantiate the need for employee absence from work....Claims
- ...Job purpose The position of UM Outpatient Review Nurse reports to the Director, Case Management... ...Management team and is responsible for clinical, quality, and patient outcomes. This... ...process. Review member’s utilization and claim history when processing a referral. Maintain...ClaimsWork at officeRemote workFlexible hoursWeekend work
$100 - $120 per hour
...inpatient expertise you already have. The clinical AI systems everyone is talking about are... ...teams building them need physicians who can review inpatient records and structured clinical... ...up the AI's clinical information and claims, write the clinical answer a professional...ClaimsHourly payPart timeFor contractorsRemote workFlexible hoursOpenTrain AI
New York, NY12 hours ago- ...Health Business Solutions LLC is seeking a Clinical Appeals Nurse (RN) for a remote role. The position focuses on reviewing denied claims for clinical accuracy and medical necessity, developing appeal strategies, and drafting payer-ready documentation to overturn denials...ClaimsRemote work
Health Business Solutions
New York, NY2 days ago - ...CorVel in the United States is seeking a Utilization Review Case Manager to gather demographic and clinical information, certify medical necessity, and assign... ...documentation, data analysis, and collaboration with claims staff, attorneys and providers to support the Case Management...ClaimsRemote work
NurseRemotely
New York, NY3 days ago - ...Dane Street, LLC is seeking an experienced Registered Nurse to perform reviews and clinical summaries for disability claims. Reports must generally be completed with a 2-day turnaround, following a thorough training on the Dane Street portal and report formatting. Training...Claims
Dane Street
New York, NY4 days ago - ...Mutual of Omaha Insurance Co. is seeking a knowledgeable Clinical Nurse Consultant – Long-Term Care to provide clinical expertise and support claims management through medical reviews, analysis, and return-to-work guidance. The role evaluates medical information related...ClaimsRemote work
Mutual of Omaha Insurance Company
New York, NY4 days ago - ...Guardian Life is seeking an RN Clinical Consultant to support disability claim evaluations. You will review medical information, assess functional capacity, and provide clinical guidance to inform claim decisions. The role requires independent judgment, strong communication...ClaimsRemote work
Guardian Llc
New York, NY2 days ago - ...Peraton is seeking a Medical Reviewer to join the SafeGuard Services team. The role involves... ...medical record reviews, applying clinical judgment to payment decisions, and researching... ...will have a clinical background, active nursing or therapy license, strong investigative...ClaimsRemote work
Peraton
New York, NY15 hours ago - TalentLNX LLC seeks a remote Clinical Claims Review RN to audit hospital claims line by line against medical records, ensuring charges are ordered... ..., documented, and supported. The role blends acute care nursing judgment with chart auditing, coding, and revenue integrity...ClaimsRemote job
$68.97k - $113.31k
...Overview Are you a registered nurse who is passionate about helping... ...? Guardian is seeking an RN Clinical Consultant to serve as a clinical... ...term and long-term disability claims. In this role, you will... ...claims management systems You will Review short-term and long-term disability...ClaimsFull timeTemporary workH1bWork at officeRemote workFlexible hours- R1 RCM Inc. is seeking a Clinical Coding Appeals Nurse to review medical records and draft appeals of denied or underpaid claims. You will apply clinical judgment to DRG downgrades and prepare persuasive letters using ICD-9/10 CM & PCS, CPT, HCPCS, and NCCI guidance. This...ClaimsRemote job
- ...authorization and concurrent review. Provides monthly telephonic... ...community resources. Applies clinical knowledge to work with facilities... ...of care and accurate claims payment. May also manage appeals... ...state of NY Requires an AS/BS in Nursing At least 2 years of acute...ClaimsContract workRemote workMonday to FridayFlexible hours
HealthCare Support
New York, NY4 days ago - BlueCross BlueShield of South Carolina is seeking an experienced RN to perform medical claim reviews remotely, leveraging clinical information and established guidelines. This full-time role supports medical claims and utilization practices during our standard business...ClaimsRemote jobFull timeWork at office
$28.94 - $51.83 per hour
Ssbv Clinical Claims Review Rn Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits...ClaimsHourly payMinimum wageFull timeTemporary workWork experience placementWork at officeLocal areaRemote workHome office- RN / Medical Reviewer / Remote Job Details Professional Discipline : Registered Nurse Specialty : Utilization Review Employment Type... ...regarding benefits and clinical criteria and assess and monitor... ...your clinical proficiency and claims knowledge. This is a REMOTE...ClaimsRemote jobFull timeContract workLocal areaShift work
$78k - $99.2k
...are seeking a talented individual for a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized medical bill, and UB-04 forms to ensure... ...billing practices. This position requires clinical review expertise, as well as itemized bill review...ClaimsFull timeRemote workWork from homeFlexible hoursGainwell Technologies LLC
New York, NY2 days ago$173.4k - $204k
...rise. Job Summary: SmithRx is looking for a motivated Senior Clinical Review Operations Pharmacist to serve as a clinical subject matter expert... ...with internal teams to troubleshoot eligibility questions, claims adjudication, and benefit design nuances. Clinical Policy & P...ClaimsTemporary workFlexible hours$29 - $52 per hour
Optum Clinical Claim Review Nurse Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits...ClaimsHourly payMinimum wageFull timeContract workTemporary workWork experience placementWork at officeLocal areaRemote work- ...Competencies: CPS_Conduct Non-Clinical Research to Support Determinations... ...to the appropriate team for review (e.g., Medicare, Medicaid,... ...approaches to the practice of nursing, in order to achieve or enhance... ...processes (e.g., assessments, case/claim loads, previous...ClaimsWork at officeRemote work
Optum
New York, NY3 days ago $66.66k - $96.1k
...Responsibilities and Requirements KEY RESPONSIBILITIES Reviews all medical (and other) documentation in claim files to answer the specific questions posed by... ...management can be appropriately addressed by the Clinical Nurse Specialist. If not, refer the file to the...ClaimsWork at officeImmediate startFlexible hoursShift work
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