RN Clinical Claims Review Specialist

CVS Health; Manchester (NH); On-site; USD 36,000 - 77,000; Full time

Job summary

CVS Health in Manchester, NH is seeking a Clinical Claim Review Nurse to evaluate and interpret clinical information for member and provider claims. The role requires RN licensure, 2–3 years of experience, and strong data-driven decision making.

The position is full-time with a 40-hour work week, offering comprehensive benefits and opportunities for cross-functional collaboration with claims processing teams. Location is on-site in Manchester, NH.

Qualifications

• Strong analytical skills to assess medical claims.
• Nursing licensure (RN) with professional experience.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to determine appropriate criteria 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 report discrepancies or potential fraud to leadership.
• Stay updated on applicable laws, regulations, and internal workflows.

Skills

Analytical skills

Education

Associates Degree in Nursing

Bachelor of Science in Nursing preferred

Job description

CVS Health in Manchester, NH is seeking a Clinical Claim Review Nurse to evaluate and interpret clinical information for member and provider claims. The role requires RN licensure, 2–3 years of experience, and strong data-driven decision making.

The position is full-time with a 40-hour work week, offering comprehensive benefits and opportunities for cross-functional collaboration with claims processing teams. Location is on-site in Manchester, NH.