Appeals Nurse Consultant
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Job Description
Appeals Nurse Consultant reviewing and resolving clinical appeals for CVS Health and Aetna. Applying clinical criteria, policies, and regulatory knowledge in a 100% remote role.
Responsibilities:
- Review and resolve clinical appeals
- Review documentation and interpret data from clinical records
- Apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements
- Address member and provider issues
- Coordinate clinical resolution independently with internal and external clinician support as required
- Support UM, including expedited appeals, MPO, Coding, or Behavioral Health appeals
- Work full-time in a telework arrangement
Requirements:
- Active and unrestricted RN licensure in state of residence
- 3+ years clinical experience
- Associate's Degree minimum
- Appeals, Managed Care, or Utilization Review experience preferred
- Proficiency with computer skills including navigating multiple systems preferred
- Exceptional communication skills preferred
- Time efficient, highly organized, and ability to multitask preferred
- Dedicated workspace free of interruptions
- Separate care arrangements for dependents during work hours
- Availability for standard Monday–Friday, 8:00 AM to 5:00 PM local-time hours
- Occasional weekend and holiday on-call coverage may be required
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
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