Appeals Nurse Consultant (Remote)
About The Position
CVS Aetna is seeking a dedicated Appeals Nurse Consultant for a remote role supporting fair and accurate resolution of clinical appeals. The position applies clinical judgment and regulatory knowledge to appeals involving members and providers. The nurse reviews clinical documentation, interprets information from clinical records, and applies appropriate clinical criteria and policies consistent with regulatory and accreditation requirements. The role independently coordinates clinical resolutions with internal or external clinician support as needed and may support UM (including expedited), MPO, Coding, or Behavioral Health appeals. This is a 100% remote, full-time telework position with standard hours Monday through Friday, 8:00 AM to 5:00 PM local time. Candidates must have a dedicated workspace free of interruptions, and dependents must have separate care arrangements during work hours. Occasional weekend and holiday on-call coverage may be required.
Requirements
- Active and unrestricted RN licensure in the state of residence.
- At least 3 years of clinical experience.
- At least an associate's degree.
- Maintain a dedicated remote workspace free of interruptions.
- Ensure dependents have separate care arrangements during work hours.
Nice To Haves
- Appeals, Managed Care, or Utilization Review experience.
- Computer proficiency, including the ability to navigate multiple systems.
- Exceptional communication skills.
- Time efficiency, strong organization, and the ability to multitask.
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 for member and provider issues.
- Independently coordinate clinical resolution with internal or external clinician support as required.
- Support UM (including expedited), MPO, Coding, or Behavioral Health appeals as needed.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
