Remote RN: Clinical Claims Reviewer

CVS Health; California; Hybrid; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health is seeking a licensed RN to exercise clinical judgment in processing post-service claims, reviewing clinical documentation and applying criteria. You will coordinate resolutions with clinicians, train staff, identify trends, and ensure HIPAA compliance while supporting customer service and claims teams.

The role requires strong analytical skills with experience in medical claims and working from home with reliable internet access.

Qualifications

• RN license required.
• Minimum 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 utilize appropriate 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 leadership feedback on discrepancies or potential fraud.
• Ensure compliance with applicable laws, regulations and internal workflows.

Skills

Analytical skills

Clinical judgment

Education

RN license

Tools

EHR portal

Microsoft Office 365

Job description

CVS Health is seeking a licensed RN to exercise clinical judgment in processing post-service claims, reviewing clinical documentation and applying criteria. You will coordinate resolutions with clinicians, train staff, identify trends, and ensure HIPAA compliance while supporting customer service and claims teams.

The role requires strong analytical skills with experience in medical claims and working from home with reliable internet access.