Position Summary
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. This role serves as a clinical resource for internal teams, supports training and knowledge sharing, identifies trends or potential discrepancies, and ensures compliance with regulatory, state, and organizational requirements.
Additional 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. WiFi and satellite internet are not permitted.
- 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. The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
- If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
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. Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
- Future Growth: Openness to learning new skills in the future as the workplace environment evolves
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).
- Strong digital communication skills, including email, Teams messaging, virtual meetings, and calendar management.
Preferred Qualification
- Please refer to the required qualification section.
Education
- Associate degree in Nursing.
Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range
The typical pay range for this role is
$29.10 - $62.32