Clinical Claim Review Nurse

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

This is a fully remote Clinical Claim Review Nurse opportunity. The schedule is Monday - Friday, 8am-5pm in the time zone where the candidate resides.

Responsible for the review and evaluation of clinical information and documentation related to outpatient therapy services. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for customer service and claims processing areas.

Required Qualifications

• 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, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews

Work from Home Requirements:
• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download
speed of 50 Mbps download and 5 Mbps upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA
guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or
standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:
• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks
and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong
passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet
connection issues, and contacting IT for unresolved technical issues.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Preferred Qualifications

• Experience with MedCompass, CEC, IOP, or clinical review experience with therapy review types
• Experience working with adults and/or pediatrics outpatient therapy, i.e. occupational therapy, physical therapy, speech therapy, chiropractic, or acupuncture
• Experience working in a multidisciplinary team

Education

• Minimum of an Associate’s degree in Nursing or Diploma RN
• Bachelor’s in Science & Nursing preferred

Anticipated Weekly Hours

40

Time Type

Full time

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

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