Appeals Nurse Consultant (Remote)
About The Position
CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join its remote team. The role helps ensure fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge. It is a full-time, 100% remote 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. The position is anticipated to work 40 hours per week and may support UM (including expedited), MPO, Coding, or Behavioral Health appeals.
Requirements
- Active and unrestricted RN licensure in the state of residence.
- At least 3 years of clinical experience.
- At least an associate's degree.
- Ability to maintain a dedicated workspace free of interruptions for remote work.
- Dependents must have separate care arrangements during work hours.
Nice To Haves
- Experience in appeals, managed care, or utilization review.
- Proficiency with computer skills, including navigating multiple systems.
- Exceptional communication skills.
- Time efficiency, strong organization, and ability to multitask.
Responsibilities
- Review and resolve clinical appeals.
- Review documentation and interpret clinical-record data to 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 assigned.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Other resources, based on eligibility.
- Eligible 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
