Remote RN: Clinical Claims Reviewer

Colorado Psychiatric; Colorado; Remote; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking an RN with 2-3 years of clinical experience to review medical documentation and apply clinical criteria for post-service claims. You will coordinate resolutions, support customer service and claims teams, and train staff while ensuring HIPAA compliance.

Responsibilities include identifying trends, flagging discrepancies, and staying current with laws and internal workflows to maintain regulatory compliance across the organization.

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.

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

Analytical skills

Education

Nursing degree (RN)

Tools

VPN access

EHR portal

Microsoft Office 365

Job description

CVS Health is seeking an RN with 2-3 years of clinical experience to review medical documentation and apply clinical criteria for post-service claims. You will coordinate resolutions, support customer service and claims teams, and train staff while ensuring HIPAA compliance.

Responsibilities include identifying trends, flagging discrepancies, and staying current with laws and internal workflows to maintain regulatory compliance across the organization.