Clinical Claims Review Nurse

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

📋 Description

• Evaluate and analyze clinical documentation sourced from medical records or systems.

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

• Manage clinical resolutions autonomously, seeking clinician/MD assistance as necessary.

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

• Onboard new staff and facilitate cross-training for existing team members.

• Detect trends and offer insights to leadership concerning discrepancies or potential fraudulent activities.

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

⛳️ Requirements

• Active, current, and unrestricted Registered Nurse license in your state of residence.

• Nursing degree (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.

• Bachelor's degree.

• Capability to keep up-to-date with relevant laws, regulations, and internal processes.

• Ability to adhere to organizational and state-specific requirements.

🏝️ Benefits

• 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, alongside base pay.