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 customer service and claims processing teams.

• Facilitate training for new team members and provide cross-training for existing staff.

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

• Stay updated on relevant laws, regulations, and internal processes to ensure compliance with organizational and state-specific requirements.

⛳️ Requirements

• 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.

• A minimum of an Associate’s Degree in Nursing or a Diploma RN is required.

• A Bachelor's degree in Science & Nursing is preferred.

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

• Minimum internet speed of 50 Mbps for download and 5 Mbps for upload is required.

• WiFi and satellite internet connections are not allowed.

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

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

• Capability to use multiple monitors and navigate various applications is essential.

• Ability to communicate through email, calendar invites, Teams messaging, and virtual meetings is required.

• Experience with Microsoft Office 365 applications or similar Google Workspace applications is preferred.

• Capacity to log into secure systems such as VPN and EHR portals is necessary.

• Must be able to follow computer security practices, manage strong passwords, and recognize suspicious emails or links.

• Ability to troubleshoot common technical issues independently is required.

• Must meet the required internet speeds and comply with all Work From Home requirements.

🏝️ Benefits

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance 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.).