Clinical Claim Review Nurse

This is a fully remote position, open to applicants in Alabama, +44 more states.

📋 Description

• Assess and analyze clinical information and documentation.

• Interpret data from clinical records or systems while applying relevant clinical criteria and policies to post-service claims.

• Independently coordinate clinical resolutions, seeking clinician/MD support when necessary.

• Review claims for payment in accordance with clinical policies, legislation, regulatory standards, and plan benefits.

• Utilize multiple system applications and reach out to internal departments or providers as required.

• Serve as a resource for customer service and claims processing teams.

• Provide training for new staff and offer cross-training to current team members.

• Identify trends and communicate feedback to leadership concerning discrepancies or potential fraudulent activities.

• Stay informed on relevant laws, regulations, and internal processes to ensure compliance.

• Safeguard member information by following confidentiality policies.

⛳️ Requirements

• Nursing degree (RN) is required.

• An Associate's Degree in Nursing is necessary.

• A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN) or equivalent clinical experience is required.

• Strong analytical abilities to evaluate medical claims.

• Proficiency in computer skills, particularly with Microsoft Suite.

• Experience in Utilization Management is preferred.

• A Bachelor of Science in Nursing is preferred.

• Capability to adhere to applicable laws, regulations, company policies, procedures, confidentiality mandates, and state-specific requirements.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being, depending on eligibility.