Clinical Claims Review Nurse

CVS Health

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

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

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation review and interpretation, applying clinical decision-making for claims processing while ensuring compliance with regulations. Proficient in utilizing technology for communication and managing secure systems effectively.

Highest-signal resume keywords

Nursing Degree (RN)Clinical Decision-MakingAnalytical SkillsMicrosoft Office 365EHR Portal Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewClaims ProcessingTrend IdentificationFraud DetectionTechnical Issue Resolution

Soft Skills

Communication SkillsTraining and MentoringProblem-SolvingAdaptability

Tools & Technologies

VPNEHR PortalsMultiple MonitorsTeams Messaging

Certifications & Qualifications

Registered Nurse (RN)

Industry Keywords

HIPAA ComplianceClinical CriteriaPost-Service ClaimsState-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 to 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, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted
Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Must provide own workspace furniture
Comfortable setting up and using multiple monitors and navigating 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 resolve common technical issues independently
Openness to learning new skills as the workplace environment evolves

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
Company-provided equipment (keyboard, monitor, computer, headset, etc.)
CVS Health bonus, commission or short-term incentive program eligibility