Appeals Nurse Consultant (Remote)

CVS Health

4d • Remote

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will be responsible for processing the medical necessity of Medicare appeals for participating providers. Key Responsibilities Requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare Guidelines, navigate through multiple computer system applications in a fast-paced department. Must work independently as well as in a team environment while working remotely. Fast paced sedentary position, talking on the telephone, looking at computer screens, utilizing templates in Word, and typing on the computer. 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 provider issues. This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). No weekends or holidays required. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Requirements

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.

Nice To Haves

• Appeals, Managed Care, or Utilization Review experience.
• Pre Certification or Pre Authorization experience
• Proficiency with computer skills including navigating multiple systems.
• Exceptional communication skills.
• Time efficient, highly organized, and ability to multitask.

Responsibilities

• Requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare Guidelines, navigate through multiple computer system applications in a fast-paced department.
• Must work independently as well as in a team environment while working remotely.
• Fast paced sedentary position, talking on the telephone, looking at computer screens, utilizing templates in Word, and typing on the computer.
• 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 provider issues.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees