Clinical Claims Review Nurse

This is a fully remote position, open to applicants in North Dakota.

📋 Description

• Analyze and interpret clinical documentation sourced from medical records or systems.

• Implement clinical decision-making along with relevant clinical criteria and policies for post-service claims.

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

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

• Provide training for new employees and cross-train current team members.

• Identify trends and offer feedback to leadership regarding discrepancies or potential fraudulent activities.

• Keep updated with applicable laws, regulations, and internal workflows to ensure adherence to organizational and state-specific requirements.

⛳️ Requirements

• Bachelor's degree in Nursing (RN).

• At least 2–3 years of professional experience as a licensed Registered Nurse (RN) or equivalent clinical experience.

• Strong analytical abilities to evaluate medical claims.

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

• Minimum internet speed of 50 Mbps for downloads and 5 Mbps for uploads.

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

• Must reside and work within the same state and city.

• Capability to use multiple monitors and navigate various applications simultaneously.

• Proficient communication skills via email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications or comparable Google Workspace applications.

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

• Knowledge of computer security practices, including screen locking, strong password management, and recognizing suspicious emails or links.

• Competence in troubleshooting common technical issues independently.

• Willingness to learn new skills as the workplace evolves.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.