Clinical Claims Review Nurse

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

📋 Description

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

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

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

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

• Train new hires and offer cross-training to current team members.

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

• Stay updated with applicable laws, regulations, and internal workflows to ensure compliance with both 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 for assessing 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, and private designated home virtual work location that complies with CVS Health and HIPAA guidelines.

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

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

• Proficiency in communicating via email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or equivalent Google Workspace applications.

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

• Proficiency in managing strong passwords and recognizing suspicious emails or links.

• Ability to independently resolve common technical issues.

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

• Qualified candidates with arrest or conviction records will be considered in accordance with federal, state, and local laws.

🏝️ Benefits

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

• 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.).