Clinical Claims Review Nurse

CVS Health•Work At Home-Kansas, KS

21h•$26 - $69•Remote

About The Position

The Clinical Claims Review Nurse exercises clinical judgment to review post-service claims. The nurse reviews and interprets clinical documentation from medical records or systems, applies appropriate clinical criteria and policies, coordinates clinical resolutions independently or with clinician/MD support, and serves as a resource to customer service and claims processing teams. The role also includes training new staff, cross-training existing team members, identifying trends and reporting discrepancies or potential fraud to leadership, and maintaining knowledge of applicable laws, regulations, and internal workflows to support compliance with organizational and state-specific requirements. This is a full-time, work-from-home position requiring a quiet, secure, private, and compliant home workspace, a wired internet connection meeting specified speed requirements, and the ability to work uninterrupted during work hours. CVS Health provides computer equipment and related peripherals; the colleague supplies workspace furniture. The role involves working with multiple monitors and applications, digital communication and collaboration tools, and secure systems, while following cybersecurity practices and resolving common technical issues.

Requirements

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.
Have or be able to obtain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
Maintain a quiet, secure, private, tidy, organized, and distraction-free home work location that complies with CVS Health and HIPAA guidelines and allows uninterrupted work during work hours.
Work from within the state and city where the colleague has confirmed they currently live.
Provide personal workspace furniture, such as a desk or standing desk, for extended periods of desk work.
Be comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
Communicate using digital channels such as email, calendar invites, Teams messaging, and virtual meetings.
Have experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, and PowerPoint) or similar tools such as Google Workspace.
Access secure systems such as VPNs and EHR portals, lock the computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Resolve common technical issues independently and contact IT for issues that cannot be resolved.
Commit to meeting required internet speeds and adhering to all work-from-home requirements if hired.

Responsibilities

Review and interpret clinical documentation obtained from medical records or systems.
Apply clinical decision-making and appropriate clinical criteria and policies to post-service claims.
Coordinate clinical resolutions independently, with clinician or 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 about discrepancies or potential fraudulent activities.
Remain current with applicable laws, regulations, and internal workflows to ensure compliance with organizational and state-specific requirements.