Clinical Claims Review Nurse

Job not on LinkedIn

🔥 14 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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 • Serve as a resource for customer service and claims processing teams • Train new staff and provide cross-training to existing team members • Identify trends and report discrepancies or potential fraudulent activities to leadership • Maintain current knowledge of applicable laws, regulations, and internal workflows to ensure compliance with organizational and state-specific requirements

🎯 Requirements

• 5+ years of clinical experience • 2+ years of experience as a registered nurse • Active, current, and unrestricted RN licensure in the state of residence • Experience using Microsoft Office products, including Outlook and Excel • Previous experience using Internet Explorer and Google Chrome • Willingness to work Monday through Friday, 8am–5pm in the time zone of residence • Associate degree required • Utilization Management review preferred • Managed Care experience preferred • Client processing experience preferred

🏖️ 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 in addition to base pay