Appeals Nurse Consultant (Remote)

CVS Health•Work At Home-Massachusetts, MA

3d•$66,575 - $142,576•Remote

About The Position

CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join its remote team. The role supports fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge. The consultant reviews clinical documentation, interprets data, applies appropriate clinical criteria and policies, and coordinates clinical resolutions with internal or external clinician support as needed. The work may support UM (including expedited), MPO, Coding, or Behavioral Health appeals. This is a 100% remote, full-time telework position. Candidates must have a dedicated workspace free of interruptions, and dependents must have separate care arrangements during work hours. Standard hours are Monday through Friday, 8:00 AM to 5:00 PM local time; 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.
Associate's degree minimum.
Ability to work remotely from a dedicated workspace free of interruptions.
Dependents must have separate care arrangements during work hours.

Nice To Haves

Appeals, Managed Care, or Utilization Review experience.
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 data from clinical records.
Apply appropriate clinical criteria and policies in accordance 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.