Appeal Nurse Associate - MUST live in KY

CVS Health • Frankfort, KY

407d • $43,888 - $91,062 • Remote

About The Position

The Appeal Nurse Associate role at CVS Health is a full-time telework position focused on facilitating the delivery of healthcare benefits and information. The position involves reviewing clinical complaints, grievances, and appeals, ensuring compliance with regulatory and accreditation standards, and coordinating clinical resolutions. The role requires a strong understanding of clinical criteria, benefit plans, and regulatory requirements, with a commitment to promoting member wellness and timely return to work.

Requirements

• 2+ years of clinical experience
• LPN/LVN with current unrestricted state licensure in Kentucky
• Must reside in the state of Kentucky

Nice To Haves

• Managed Care experience
• Prior Appeals experience

Responsibilities

• Facilitate the delivery of appropriate benefits and healthcare information to determine eligibility.
• Support health strategies, policies, and programs to ensure the delivery of benefits and member wellness.
• Review and resolve clinical complaints, grievances, and appeals.
• Interpret data from clinical records to apply clinical criteria and policies in line with regulations.
• Coordinate clinical resolutions with internal and external clinician support as required.
• Assist in reviewing clinical complaint and appeal requests, considering previous information and additional records.
• Gather data by navigating multiple system applications and contacting providers or internal departments for information.
• Ensure cases are reviewed by practitioners with clinical expertise for appeal issues.
• Apply regulatory and accreditation standards to process appeals and ERO requests within requirements.
• Condense information from multiple sources into a clear clinical picture for presentation to clinicians.

Benefits

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Employee Stock Purchase Plan
• Fully-paid term life insurance
• Short-term and long-term disability benefits
• Well-being programs
• Education assistance
• Free development courses
• CVS store discount
• Paid Time Off (PTO)
• Paid holidays

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Health and Personal Care Retailers
• Education Level: Associate degree