Clinical Claims Review Nurse

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🌾 North Dakota – Remote

🌾 North Dakota – 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.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 to ensure compliance with organizational and state-specific requirements

🎯 Requirements

• 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 • Minimum of an Associate’s Degree in Nursing or Diploma RN • Bachelor’s in Science & Nursing preferred • 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 and 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 use multiple monitors and navigate multiple applications • Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings • Experience with Microsoft Office 365 applications or similar Google Workspace applications • 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 independently • Must be able to obtain required internet speeds and adhere to all Work From Home requirements

🏖️ Benefits

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

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