Appeals Nurse Consultant
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Job Description
Appeals Nurse Consultant reviewing clinical records and resolving member and provider appeals for CVS Health. Applying clinical criteria, policies, and regulatory requirements remotely.
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
- Independently coordinate clinical resolution with internal and external clinician support as required
- Support UM (including expedited), MPO, Coding, or Behavioral Health appeals
- Work Monday–Friday, 8:00 AM to 5:00 PM local time
- Provide occasional weekend and holiday on-call coverage as required
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
- Proficiency with computer skills including navigating multiple systems
- Exceptional communication skills
- Time efficient, highly organized, and ability to multitask
- Dedicated workspace free of interruptions
- Dependents must have separate care arrangements during work hours
Benefits:
- 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
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