Clinical Claims Review Nurse
CVS Health•Work At Home-North Dakota, ND
•$26 - $69•Remote
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. This role requires the nurse to exercise clinical judgment and perform the following duties:
Requirements
- Must have active current and unrestricted Registered Nurse licensure in state of residence
- 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
Responsibilities
- Review and interpret clinical documentation obtained from medical records or systems.
- Apply clinical decision-making to utilize 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 organizational and state-specific requirements
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
