Clinical Claim Review Nurse

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

As a Clinical Claim Review Nurse, you will leverage your clinical expertise to review medical records and post-service claims, apply established clinical criteria and policies, and support accurate claim determinations.

Responsibilities

• Review and interpret clinical documentation from medical records and other systems.
• Apply clinical judgment, criteria, and policies to evaluate post-service claims.
• Coordinate clinical resolutions independently, consulting with clinicians or physicians as needed.
• Serve as a clinical resource to customer service and claims processing teams.
• Support the training and cross-training of team members.
• Identify trends, discrepancies, or potential fraud concerns and escalate findings to leadership.
• Maintain current knowledge of applicable laws, regulations, policies, and workflows to ensure compliance.

Work from Home Requirements

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 50 Mbps download and 5 Mbps upload.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license.
• Minimum of 2 years of professional experience as a Registered Nurse (RN) in any clinical setting or specialty area.
• Strong analytical and critical thinking skills, with the ability to review, interpret, and evaluate medical claims and clinical documentation.
• Associate's or Bachelor's degree in Nursing (RN) from an accredited program.
• Proficiency with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar platforms (e.g., Google Workspace).

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs

Pay Range

$29.10 - $62.32