Appeals Nurse Consultant- MUST live in KY

CVS Health•Work At Home-Kentucky, KY

1d•$54,095 - $116,760

About The Position

The Appeals Nurse Consultant is responsible for intake, investigation, and resolution of appeals, complaints, and grievances across all products. The role handles cases that may involve multiple issues and coordinates responses across business units to ensure timely, customer-focused outcomes. It focuses particularly on reviewing and resolving clinical documentation, clinical complaints, and appeals. The consultant reviews clinical records, interprets data, and applies appropriate clinical criteria and policies in accordance with regulatory and accreditation requirements for member and provider issues. The role requires an unrestricted, active nursing license and independently coordinates clinical resolution with internal or external clinician support as needed. The consultant reviews clinical and benefit documentation, considers prior information and additional records, and gathers information across multiple system applications. The role may involve contacting providers of record, vendors, and internal departments for additional information; ensuring reviews are assigned to practitioners with relevant clinical expertise; and applying knowledge of delegation arrangements, coding logic, member and provider contracts, clinical criteria, benefit plan structures, and regulatory requirements. The consultant coordinates appeals with members and their representatives, providers, regulators, and internal or external participants, including fair hearings, state-mandated reviews, and appeal panel hearings. The role also reports findings, responds to rebuttal issues, recommends improvements, and identifies trends and emerging issues.

Requirements

Current, unrestricted state nursing licensure as an RN.
3–5 years of clinical experience.
3–5 years of behavioral health experience.
Experience reading or researching benefit language.
Excellent verbal and written communication skills.
Excellent customer service skills.
Must live in Kentucky.

Nice To Haves

Managed care experience.

Responsibilities

Intake, investigate, and resolve appeals, complaints, and grievances across products, coordinating responses when multiple issues or business units are involved.
Review clinical documentation, clinical complaints, appeals, and benefit documentation; consider prior information and additional records to make recommendations or reviews.
Interpret clinical-record data and apply clinical criteria, policies, regulatory standards, and accreditation requirements.
Gather information across multiple system applications and contact providers, vendors, or internal departments to obtain additional information.
Ensure that cases are reviewed by practitioners with clinical expertise appropriate to the appeal issue, including Specialty Match Review requirements.
Coordinate clinical resolution with internal and external clinician support as needed.
Coordinate appeals with members and their authorized representatives, providers, regulators, consultants, and other participants, including fair hearings and state-mandated reviews.
Ensure appeals are processed within regulatory and accreditation requirements and in accordance with state regulations and benefit plan designs.
Condense complex information into a clear and precise clinical picture while working independently.
Report findings to team leaders or supervisors, respond to rebuttal issues, and recommend improvements.
Identify trends and emerging issues, report findings, and provide input on potential solutions.