RN Clinical Claims Review Specialist

CVS Health; Boston (MA); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in Boston. The role involves reviewing clinical documentation, applying criteria for post-service claims, and coordinating resolutions with clinicians to ensure compliant claims processing.

The ideal candidate holds an RN with 2–3 years of experience and strong analytical skills, plus familiarity with Microsoft Suite and Utilization Management. Full-time on-site position with comprehensive benefits.

Qualifications

• Nursing degree (RN) required.
• 2–3 years RN experience or equivalent.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation.
• Apply clinical criteria and policies for post-service claims.
• Coordinate with clinicians to resolve issues and ensure compliant reviews.
• Serve as a resource for customer service and claims teams.
• Train new staff and provide cross-training to team members.
• Identify trends and report discrepancies or potential fraud to leadership.
• Maintain current knowledge of laws, regulations, and internal workflows.

Skills

RN

Analytical skills

Microsoft Suite

Education

Associates Degree in Nursing

BSN preferred

Job description

CVS Health is seeking a Clinical Claim Review Nurse in Boston. The role involves reviewing clinical documentation, applying criteria for post-service claims, and coordinating resolutions with clinicians to ensure compliant claims processing.

The ideal candidate holds an RN with 2–3 years of experience and strong analytical skills, plus familiarity with Microsoft Suite and Utilization Management. Full-time on-site position with comprehensive benefits.