RN Clinical Claims Reviewer

CVS Health; Hartford (CT); On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health in Hartford, CT seeks a Clinical Claim Review Nurse to evaluate post-service claims using clinical criteria and policies. You will review medical records and coordinate resolutions with clinicians, supporting claims processing while maintaining confidentiality and compliance.

The role requires an RN license and 2–3 years of clinical experience, strong analytical skills, and proficiency with Microsoft Office. This is a full-time position with comprehensive benefits.

Qualifications

• Nursing degree (RN)
• A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN)
• Strong analytical skills to assess medical claims

Responsibilities

• 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.

Skills

Analytical skills

RN experience

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Microsoft Suite

Job description

CVS Health in Hartford, CT seeks a Clinical Claim Review Nurse to evaluate post-service claims using clinical criteria and policies. You will review medical records and coordinate resolutions with clinicians, supporting claims processing while maintaining confidentiality and compliance.

The role requires an RN license and 2–3 years of clinical experience, strong analytical skills, and proficiency with Microsoft Office. This is a full-time position with comprehensive benefits.