Clinical Claim Review Nurse

Job not on LinkedIn

🔥 6 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.Why this score:

• Just posted.
• Jobs at this company usually fill in 21 days.

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Review and interpret clinical documentation from medical records and other systems • Apply clinical judgment, established clinical 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 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 • Support accurate claim determinations

🎯 Requirements

• 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 • Ability to review, interpret, and evaluate medical claims and clinical documentation • Associate's or Bachelor's degree in Nursing (RN) from an accredited program • Associate degree in Nursing • Proficiency with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar platforms such as Google Workspace • Strong digital communication skills, including email, Teams messaging, virtual meetings, and calendar management • Ability to set up and use multiple monitors and navigate multiple applications simultaneously • Ability to log in to secure systems such as VPN and EHR portals • Ability to manage strong passwords and recognize suspicious emails or links • Ability to resolve common technical issues independently • Direct/hardwired internet connection to a modem/router within 7 feet of the computer • Minimum internet speed of 50 Mbps download and 5 Mbps upload • Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines • Must work within the state and city where currently living • Ability to provide workspace furniture, including a desk or standing desk • Ability to obtain required internet speeds and adhere to all Work From Home requirements

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility • Company-provided work equipment (keyboard, monitor, computer, headset, etc.)

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