Clinical Claims Review Nurse

CVS Health

. Review and interpret clinical documentation from medical records or systems .

Posted 10/22/2026full-timeRemote • Kansas • United StatesJuniorMid-Level💰 $26 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical documentation review and decision-making, ensuring compliance with healthcare regulations and organizational policies. Proficient in utilizing Microsoft Office 365 and secure systems while providing training and support to team members.

Highest-signal resume keywords

Registered Nurse (RN)Clinical Documentation ReviewAnalytical Skills for Medical ClaimsMicrosoft Office 365HIPAA Compliance

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Decision-MakingClaims ProcessingTrend IdentificationTechnical TroubleshootingEHR Navigation

Soft Skills

Training and MentoringCommunication SkillsProblem-Solving

Tools & Technologies

Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPoint

Certifications & Qualifications

Nursing Degree (RN)

Industry Keywords

Healthcare ComplianceClinical CriteriaFraud DetectionVirtual Work EnvironmentState-Specific Requirements

About the role

Key responsibilities & impact

Review and interpret clinical documentation from medical records or systems
Apply clinical decision-making and 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 regarding discrepancies or potential fraudulent activities
Remain current with applicable laws, regulations, and internal workflows
Ensure compliance with organizational and state-specific requirements

Requirements

What you’ll need

Nursing degree (RN)
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
Direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 50 Mbps download and 5 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Must provide own workspace furniture
Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace experience
Ability to navigate multiple monitors and applications
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Ability to log in to secure systems such as VPN and EHR portals
Ability to follow computer security practices, manage strong passwords, and recognize suspicious emails or links
Ability to troubleshoot common technical issues
Openness to learning new skills as the workplace evolves

Benefits

Comp & perks

Company-provided equipment (keyboard, monitor, computer, headset, etc.)
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