Clinical Claims Review Nurse

CVS Health•Work At Home-North Dakota, ND

3d•$29 - $62•Remote

About The Position

The Clinical Claims Review Nurse uses clinical judgment to review post-service claims and interpret clinical documentation obtained from medical records or systems. The nurse applies clinical decision-making and appropriate clinical criteria and policies, coordinates clinical resolutions independently or with clinician/MD support as needed, and serves as a resource to customer service and claims processing teams. The role also supports staff training, identifies trends or possible discrepancies and fraudulent activities, and maintains current knowledge of applicable laws, regulations, and internal workflows to ensure compliance with organizational and state-specific requirements. This is a full-time, 40-hour-per-week work-from-home role. The employee must work from the state and city where they have confirmed residence and maintain a quiet, secure, private workspace that complies with CVS Health and HIPAA guidelines. A wired internet connection to a modem/router within seven feet of the computer is required, with at least 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted. The company provides computer equipment, while the employee supplies workspace furniture. The role requires extended periods at a desk and comfort using multiple monitors, applications, communication tools, secure systems, and common troubleshooting procedures. The typical pay range is $29.10–$62.32 per hour. The position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. Eligible full-time benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources. The application window is anticipated to close on 11/04/2026.

Requirements

At least 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience.
Strong analytical skills to assess medical claims.
Minimum of an Associate’s Degree in Nursing or Diploma RN.
Ability to obtain and use a direct/hardwired internet connection to a modem/router within seven 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, designated home work location that is free from distractions, organized, compliant with CVS Health and HIPAA guidelines, and suitable for uninterrupted work.
Work from the state and city where the employee has confirmed they currently live.
Provide workspace furniture, such as a desk or standing desk, and commit to meeting work-from-home requirements.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to communicate through digital channels such as email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
Ability to access secure systems such as a VPN or EHR portal, secure unattended devices, manage strong passwords, and recognize suspicious emails or links.
Ability to troubleshoot common technical issues independently and contact IT when necessary.
Openness to learning new skills as the workplace evolves.

Nice To Haves

Bachelor’s in Science & Nursing.

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.