Clinical Claims Review Nurse
$26.01 - $68.55 per hourISHE
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. 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 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 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 ISHE
- CVS Health is seeking a licensed RN to review and interpret clinical documentation for post-service claims, applying clinical criteria to ensure accurate processing. The role coordinates resolutions independently with clinician support as required. In this full-time position...ClaimsFull time
$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
- 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
$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 Friday- 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
$26.01 - $68.55 per hour
...community at a time. This role requires the nurse to exercise clinical judgment and perform the following duties: Review and interpret clinical documentation obtained... ...clinical 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
- 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
- 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 job
- 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
- 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 job
- 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
- 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
$68.97k - $113.31k
Are you a registered nurse who is passionate about helping individuals... ...? Guardian is seeking an RN Clinical Consultant to serve as a... ...term and long-term disability claims. In this role, you will analyze... ...management systems You will Review short-term and long-term disability...ClaimsFull timeTemporary workH1bWork at officeRemote workVisa sponsorshipWork visaFlexible hours- 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
$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$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- ...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
- Clinical Appeals Nurse (RN) Status: Exempt Location: Remote Department: Clinical Appeals Reports To: Director of Clinical Appeals Position... ...Nurse supports HBiz’s revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing...ClaimsRemote work
$29 - $52 per hour
...Program Integrity Clinical Compliance Auditor Optum Insight is improving... ...for performing compliance reviews of medical and administrative... ...care providers who submit claims for payment. This position will... ...equivalent work experience ~ Nurse licensure (RN or LPN) with a current...ClaimsHourly payMinimum wageFull timeContract workWork experience placementLive inLocal areaRemote workMonday to FridayShift work- ...Locations: USA Scope The Medical Review Coordinator will perform her/... ...: Licensed Practical Nurse (current unrestricted, in state... ...degree, L.P.N. Experience: 3 years clinical nursing experience. Responsibilities... ...a notification memo to the claims office advising of the results...ClaimsRemote jobFull timeTemporary workWork at office
$81.1k - $116.48k
Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote Join... ...The specialist may also handle clinical claim appeals from providers. This position is... ...effectively with colleagues and prepare cases for review and appeals. Minimum Qualifications: RN...ClaimsRemote jobFull timeMonday to FridayShift work- ...coordinating, processing and managing all in-patient and out-patient claims from a medical standpoint to ensure proper administration of... ...subscribers to obtain medical information. Obtains request for reviews from and notifies determinations to BAD, ITS, NASCO, FEP, BMS,...ClaimsWork experience placementH1bLocal areaRelocationVisa sponsorship
- Itemized Bill and Medical Record Reviewer job at Alaffia Health. New York, NY. About Alaffia... ...team! Do you have experience reviewing claim forms and auditing provider documentation... ...medical record Auditing revenue codes against clinical documentation Confirmation of services...ClaimsRemote workFlexible hours
- ## Clinical Appeals RN - FT - Day - Revenue Integrity & Denials Mgmt... ...in our exceptional physicians, nurses and staff, as well as advanced... ...Overview**Responsible for clinical review, development, and submission... ...appeals for denied hospital claims. This role applies clinical...ClaimsFull timeTemporary workPart timeWork at officeFlexible hours
- ...exciting career opportunity available as an Clinical Appeals Nurse. This position will be Remote Work from... ...and appeals that are received after claim submission. Responsible for the... ...related to payer denials. Participate in the review of audit findings as needed. Regular and...ClaimsFull timeRemote workWork from homeMonday to Friday
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