Clinical Claim Review Nurse

This is a fully remote position, open to applicants in Alabama, +15 more locations.

📋 Description

• Analyze and interpret clinical documentation from medical records and various systems.

• Utilize clinical judgment along with established criteria and policies to assess post-service claims.

• Independently manage clinical resolutions, seeking advice from clinicians or physicians as necessary.

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

• Assist in the training and cross-training of team members.

• Detect trends, discrepancies, or potential fraud issues and report findings to leadership.

• Stay updated on relevant laws, regulations, policies, and workflows to ensure compliance.

⛳️ Requirements

• Current, unrestricted Registered Nurse (RN) license.

• At least 2 years of professional experience as a Registered Nurse (RN) in any clinical environment or specialty.

• Excellent analytical and critical thinking abilities.

• Capability to review, interpret, and evaluate medical claims and clinical documentation.

• Associate's or Bachelor's degree in Nursing (RN) from an accredited institution.

• Proficiency in Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or equivalent platforms like Google Workspace.

• Strong digital communication skills, including email, Teams messaging, virtual meetings, and calendar organization.

• Direct/hardwired internet connection to a modem/router within 7 feet of the computer.

• Minimum internet speed of 50 Mbps download and 5 Mbps upload.

• A quiet, secure, private designated workspace at home that complies with CVS Health and HIPAA guidelines.

• Ability to work from the state and city of current residence.

• Proficiency in using multiple monitors and navigating various applications.

• Capability to access secure systems such as VPN and EHR portals.

• Ability to manage strong passwords and identify suspicious emails or links.

• Skills to troubleshoot common technical issues.

• Willingness to learn new skills as the workplace evolves.

🏝️ Benefits

• Company-provided equipment (keyboard, monitor, computer, headset, etc.).

• Medical, dental, and vision insurance.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs in addition to base salary.