Clinical Claims Review Nurse

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

📋 Description

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

• Implement clinical decision-making along with suitable clinical criteria and policies for post-service claims.

• Independently coordinate clinical resolutions, with support from clinicians or MDs as necessary.

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

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

• Detect trends and communicate discrepancies or potential fraudulent activities to leadership.

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

⛳️ Requirements

• Over 5 years of clinical experience.

• More than 2 years of experience as a registered nurse.

• Active, current, and unrestricted RN licensure in the state of residence.

• Proficient in Microsoft Office applications, including Outlook and Excel.

• Previous experience using Internet Explorer and Google Chrome.

• Availability to work Monday through Friday, from 8am to 5pm in the local time zone.

• An associate degree is required.

• Experience in Utilization Management review is preferred.

• Managed Care experience is preferred.

• Client processing experience is preferred.

🏝️ 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 in addition to base salary.