Clinical Claims Review Nurse

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

📋 Description

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

• Utilize clinical decision-making alongside suitable clinical criteria and policies for post-service claims.

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

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

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

• Detect trends and provide insights to leadership regarding discrepancies or potential fraudulent activities.

• Stay updated on relevant laws, regulations, and internal workflows to ensure adherence to organizational and state-specific requirements.

⛳️ Requirements

• Degree in Nursing (RN).

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

• Excellent analytical skills to evaluate medical claims.

• A direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not acceptable.

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

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

• Must supply their own workspace furniture.

• Comfortable with setting up and utilizing multiple monitors and managing various applications simultaneously.

• Proficient in communicating 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, maintain secure computer screens, manage strong passwords, and identify suspicious emails or links.

• Capability to resolve common technical issues independently.

• Willingness to learn new skills as the workplace environment changes.

🏝️ 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.