Clinical Claims Review Nurse

Anacalifornia; California; Remote; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement options

Wellness programs

Job summary

CVS Health is seeking a licensed RN to review medical records, apply clinical criteria, and coordinate post-service claim resolutions from a home-based environment.

This full-time remote role requires strong analytical skills, adherence to HIPAA, and collaboration with service teams to improve patient care and outcomes.

Qualifications

• RN licensed and in good standing
• Minimum 2–3 years of professional RN experience
• Ability to assess medical claims with analytical rigor

Responsibilities

• Review and interpret clinical documentation from medical records
• Apply clinical criteria and policies for post-service claims
• Coordinate clinical resolutions with clinician/MD support as needed
• Act as a resource for customer service and claims teams
• Train new staff and provide cross-training
• Identify trends and report discrepancies or potential fraud
• Ensure compliance with laws, HIPAA, and internal workflows

Skills

Analytical skills

Clinical judgment

Communication skills

Education

RN Nursing degree

Job description

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

This role requires the nurse to exercise clinical judgment and perform the following duties:

• Review and interpret clinical documentation obtained from medical records or systems.
• Apply clinical decision-making to utilize 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 if discrepancies or potential fraudulent activities are identified
• Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements

Required Qualifications:

• Nursing degree (RN)
• A 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

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

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $68.55

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/29/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.