RN Clinical Claims Review Specialist

CVS Health; Maine; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical insurance

Dental coverage

Vision coverage

Paid time off

Retirement savings

Job summary

CVS Health is seeking a Clinical Claim Review Nurse in the United States to assess post-service medical claims using clinical criteria and policies. The role entails coordinating with clinicians to resolve complex cases and ensuring compliance with laws and internal procedures.

The ideal candidate holds an RN license with 2–3 years of experience, strong analytical skills, and knowledge of Utilization Management. A comprehensive benefits package is included.

Qualifications

• RN with 2–3 years of professional experience as a licensed Registered Nurse (RN) or equivalent clinical experience.
• Strong analytical skills to assess medical claims.
• Utilization Management experience is preferred.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical criteria and policies to 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 report discrepancies or potential fraudulent activities to leadership.

Skills

RN experience

Analytical skills

Utilization Management experience

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health is seeking a Clinical Claim Review Nurse in the United States to assess post-service medical claims using clinical criteria and policies. The role entails coordinating with clinicians to resolve complex cases and ensuring compliance with laws and internal procedures.

The ideal candidate holds an RN license with 2–3 years of experience, strong analytical skills, and knowledge of Utilization Management. A comprehensive benefits package is included.