Clinical Nurse

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

This role requires the nurse to exercise clinical judgment and perform the following duties:

• Review and interpret clinical documentation obtained from medical records or systems.
• Apply clinical decision-making to utilise appropriate clinical criteria and policies for post-service claims.
• Coordinate clinical resolutions independently, with clinician/MD support as required.
• Act as a resource for customer service and claims processing teams.
• Train new staff and provide cross-training to existing team members.
• Identify trends and provide feedback to leadership if discrepancies or potential fraudulent activities are identified.
• Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organisational and state-specific requirements.

Required Qualifications:

• Nursing degree (RN)
• A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience.
• Strong analytical skills to assess medical claims.

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 organised, 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.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.).

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 recognise suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: $26.01 - $68.55

Benefits: This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.