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 acupunctur