Remote RN: Clinical Claims Review & Trainer

California Nursing Students Association Incorporated; California; Remote; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking a licensed RN to review clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinician support. The role includes training staff and guiding customer service and claims teams while staying compliant with HIPAA and state requirements.

This full-time, remote-position requires a dedicated home office, reliable wired internet, and a quiet workspace.

Qualifications

• RN license with active practice in healthcare.
• 2-3 years of RN experience in clinical settings.
• Strong analytical skills to assess medical claims.

Responsibilities

• 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

Skills

RN experience

Clinical analysis

Education

RN license

Tools

MS Office 365

Google Workspace

Job description

CVS Health is seeking a licensed RN to review clinical documentation, apply decision-making for post-service claims, and coordinate resolutions with clinician support. The role includes training staff and guiding customer service and claims teams while staying compliant with HIPAA and state requirements.

This full-time, remote-position requires a dedicated home office, reliable wired internet, and a quiet workspace.