Remote RN: Clinical Claims Reviewer

CVS Health; Bismarck (ND); Remote; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical coverage

Paid time off

Wellness programs

Job summary

CVS Health is seeking an experienced RN professional to review clinical documentation and determine appropriate post-service claim decisions. The role emphasizes clinical decision-making, resolution coordination, and cross-training duties within a fully remote US-based environment.

You will support customer service and claims teams, monitor trends, and ensure compliance with applicable regulations, while maintaining HIPAA guidelines and high quality standards.

Qualifications

• RN licensure and nursing degree required.
• 2–3 years of professional RN experience.
• Strong analytical skills to assess medical claims.

Responsibilities

• Review and interpret clinical documentation from medical records or systems.
• Apply clinical decision-making to determine appropriate criteria for post-service claims.
• Coordinate clinical resolutions independently, with clinician/MD support as needed.
• 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 leadership feedback on discrepancies or potential fraud.
• Stay current with laws, regulations and internal workflows to ensure compliance.

Skills

RN licensure

Analytical skills

Claims review

Education

Nursing degree (RN)

Job description

CVS Health is seeking an experienced RN professional to review clinical documentation and determine appropriate post-service claim decisions. The role emphasizes clinical decision-making, resolution coordination, and cross-training duties within a fully remote US-based environment.

You will support customer service and claims teams, monitor trends, and ensure compliance with applicable regulations, while maintaining HIPAA guidelines and high quality standards.