Clinical Claims Review Nurse

Job not on LinkedIn

🔥 0 minutes ago

🌪️ Kansas – Remote

🌪️ Kansas – Remote

💵 $26 - $68 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Review and interpret clinical documentation from medical records or systems • Apply clinical decision-making and 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 regarding discrepancies or potential fraudulent activities • Remain current with applicable laws, regulations, and internal workflows • Ensure compliance with organizational and state-specific requirements

🎯 Requirements

• Nursing degree (RN) • 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 • 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 • WiFi and satellite internet are not permitted • 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 • Must provide own workspace furniture • Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace experience • Ability to navigate multiple monitors and applications • Ability to use email, calendar invites, Teams messaging, and virtual meetings • Ability to log in to secure systems such as VPN and EHR portals • Ability to follow computer security practices, manage strong passwords, and recognize suspicious emails or links • Ability to troubleshoot common technical issues • Openness to learning new skills as the workplace evolves

🏖️ Benefits

• Company-provided equipment (keyboard, monitor, computer, headset, etc.) • 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 in addition to base pay