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 skills along with appropriate clinical criteria and policies for post-service claims.

• Independently manage clinical resolutions, seeking clinician or MD support as necessary.

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

• Provide training for new hires and cross-train existing team members.

• Detect trends and offer insights to leadership regarding discrepancies or possible fraudulent activities.

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

⛳️ Requirements

• Active, current, and unrestricted Registered Nurse licensure in the 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 adhere to applicable laws, regulations, internal workflows, 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.

• Eligibility for CVS Health bonus, commission, or short-term incentive program.