Appeals Nurse Consultant (Remote)
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.
Requirements
- Must have active and unrestricted RN licensure in state of residence.
- 3+ years clinical experience.
- Associate's Degree minimum.
Nice To Haves
- 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.
Responsibilities
- Responsible for the review and resolution of clinical appeals.
- Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
- Independently coordinates the clinical resolution with internal/external clinician support as required.
- This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
