Clinical Claim Review Nurse

CVS Health

. Review and evaluate clinical information and documentation related to outpatient therapy services .

Posted 10/28/2026full-timeRemote • North Dakota • United StatesJuniorMid-Level💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates clinical expertise in outpatient therapy services, with a strong focus on clinical documentation review, regulatory compliance, and effective communication within a multidisciplinary team. Proficient in utilizing Microsoft Office products and secure systems for clinical decision-making and data interpretation.

Highest-signal resume keywords

Clinical Experience As An RNActive Unrestricted RN LicensureMicrosoft Office ProficiencyClinical Review ExperienceAbility To Navigate Multiple Applications

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewData InterpretationClinical Decision-MakingRegulatory ComplianceTechnical Issue ResolutionEHR Portal ManagementVPN LoginOutpatient Therapy KnowledgeTherapy Review TypesMultidisciplinary Team Collaboration

Soft Skills

Effective CommunicationOpenness To LearningCustomer Service Orientation

Tools & Technologies

Microsoft Office 365Google WorkspaceInternet ExplorerGoogle ChromeMedCompassCECIOP

Certifications & Qualifications

RN LicensureAssociate's Degree In NursingDiploma RN

Industry Keywords

Outpatient Therapy ServicesHIPAA ComplianceClinical CriteriaAccreditation RequirementsClaims Processing

About the role

Key responsibilities & impact

Review and evaluate clinical information and documentation related to outpatient therapy services
Review documentation and interpret data from clinical records or systems
Apply clinical decision-making, clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims
Independently coordinate clinical resolution with clinician/MD support as required
Act as a resource for customer service and claims processing areas
Work Monday–Friday, 8am–5pm in the candidate’s time zone

Requirements

What you’ll need

2+ years of clinical experience as an RN
Active unrestricted RN licensure in the state of residence
Experience using Microsoft Office products, including Teams, Outlook and Excel
Previous experience using Internet Explorer and Google Chrome to utilize review resources and conduct reviews
Associate’s degree in Nursing or Diploma RN required
Bachelor’s in Science & Nursing preferred
Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 50 Mbps download and 5 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure and private designated home virtual work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently residing
Ability to set up and use multiple monitors and navigate multiple applications simultaneously
Ability to communicate via email, calendar invites, Teams messaging and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals, secure computer screens, manage strong passwords and recognize suspicious emails or links
Ability to independently resolve common technical issues and contact IT when necessary
Openness to learning new skills as the workplace evolves
Experience with MedCompass, CEC, IOP, or clinical review experience with therapy review types preferred
Experience with adult and/or pediatric outpatient therapy preferred
Experience working in a multidisciplinary team preferred

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
CVS Health bonus, commission or short-term incentive program in addition to base pay
Company-provided equipment (keyboard, monitor, computer, headset, etc.)