Clinical Claims Review Nurse

CVS Health•Work At Home-North Dakota, ND

1d•$26 - $69•Remote

About The Position

The Clinical Claims Review Nurse exercises clinical judgment to review and interpret medical records and other clinical documentation, apply appropriate clinical criteria and policies to post-service claims, and coordinate clinical resolutions independently or with clinician/MD support as needed. The nurse also supports customer service and claims processing teams, trains and cross-trains colleagues, identifies trends and reports discrepancies or potential fraud to leadership, and stays current with applicable laws, regulations, and internal workflows to ensure compliance with organizational and state-specific requirements. This is a work-from-home role. Employees must work from the state and city where they have confirmed they live and maintain a quiet, secure, private, organized home workspace compliant with CVS Health and HIPAA guidelines. The position requires a direct wired internet connection within seven feet of the computer, with at least 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides computer equipment, while employees provide their own desk or standing desk. The role involves extended periods at a desk. The employee must be comfortable using multiple monitors and applications, digital communication and collaboration tools, Microsoft Office 365 or similar applications, and secure systems such as VPNs and EHR portals. The position also requires basic independent troubleshooting of common technical issues and willingness to learn new skills as the workplace evolves. The role is scheduled for 40 hours per week and is eligible for a CVS Health bonus, commission, or short-term incentive program, in addition to base pay.

Requirements

Nursing degree (RN).
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.
Ability to obtain and maintain a direct, hardwired internet connection within seven feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
A quiet, secure, private, tidy, and organized designated home workspace that complies with CVS Health and HIPAA guidelines and permits uninterrupted work.
Work from within the state and city where the employee has confirmed they currently live.
Provide personal workspace furniture, such as a desk or standing desk, and be able to work at a desk for extended periods.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to communicate through 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, protect computer and account security, and recognize suspicious emails or links.
Ability to resolve common technical issues independently, including restarting frozen applications and resolving internet connection issues.
Openness to learning new skills as the workplace environment evolves.

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.
Use multiple monitors and applications, digital communication and collaboration tools, and secure systems to perform work.
Troubleshoot common technical issues independently and contact IT for issues that cannot be resolved.