Remote RN — Clinical Claims Review & Compliance

CVS Health; Bismarck (ND); Remote; USD 40,000 - 86,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Remote work

Job summary

CVS Health is seeking an experienced RN to review clinical documentation and apply appropriate criteria for post-service claims. You will coordinate resolutions with clinicians as needed and support customer service and claims teams. The role requires strong analytical skills and HIPAA compliance.

We offer a full-time, remote work arrangement for qualified candidates residing within the United States, with a focus on accuracy, training of staff, and ongoing adherence to CVS Health policies.

Qualifications

• Current RN license in good standing.
• 2–3 years of professional RN experience.
• Experience reviewing clinical documentation for post-service claims.
• Knowledge of HIPAA regulations and state requirements.

Responsibilities

• Review and interpret clinical documentation 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.

Skills

RN licensure

Clinical documentation review

Analytical skills

Healthcare claims processing

Strong communication

Education

Associate degree in Nursing

RN diploma

BSN preferred

Tools

Microsoft Office 365

EHR systems

Job description

CVS Health is seeking an experienced RN to review clinical documentation and apply appropriate criteria for post-service claims. You will coordinate resolutions with clinicians as needed and support customer service and claims teams. The role requires strong analytical skills and HIPAA compliance.

We offer a full-time, remote work arrangement for qualified candidates residing within the United States, with a focus on accuracy, training of staff, and ongoing adherence to CVS Health policies.