Clinical Claims Review Nurse

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

📋 Description

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

• Utilize clinical decision-making skills and relevant clinical criteria and policies for post-service claims.

• Independently coordinate clinical resolutions, seeking clinician/MD support as needed.

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

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

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

• Stay updated on applicable laws, regulations, and internal workflows.

• Ensure adherence to organizational and state-specific requirements.

⛳️ Requirements

• Nursing degree (RN) required.

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

• Strong analytical skills to evaluate medical claims.

• 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.

• WiFi and satellite internet connections are not allowed.

• A quiet, secure, and private designated home virtual work location compliant with CVS Health and HIPAA guidelines.

• Must reside and work within the state and city of current residence.

• Must provide personal workspace furniture.

• Proficiency in Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications.

• Capability to navigate multiple monitors and applications.

• Ability to utilize email, calendar invites, Teams messaging, and virtual meetings.

• Proficiency in logging into secure systems such as VPN and EHR portals.

• Ability to adhere to computer security practices, manage strong passwords, and identify suspicious emails or links.

• Capacity to troubleshoot common technical issues.

• Willingness to learn new skills as the workplace evolves.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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