# Clinical Claim Review Nurse

**Company**: CVS Health
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $29.10 - $62.32
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/OH---Work-from-hom/Clinical-Claim-Review-Nurse---Fully-Remote_R1095854-1?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/job/clinical-claim-review-nurse-fb2547d6-4ee/

## Description

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

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## Skills

### Required
- Microsoft Office 365
- clinical documentation
- medical records
- Registered Nurse license

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Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/OH---Work-from-hom/Clinical-Claim-Review-Nurse---Fully-Remote_R1095854-1?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)