Appeals Nurse Consultant

CVS Health

1d • $54,095 - $116,760

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. Position Summary Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions. In particular responsible for the review and resolution of clinical documentation, clinical complaints and 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. Requires an unrestricted active nursing license. Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review. -Data gathering requires navigation through multiple system applications. -Contacts the provider of record, vendors or internal Aetna departments to obtain additional information. -Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure and regulatory requirements are required to support the appeals review. -Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals are processed within requirements. -Condenses complex information into a clear and precise clinical picture while working independently. -Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. ---Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. --Identifies trends and emerging issues and reports on and gives input on potential solutions.

Requirements

• Experience in reading or researching benefit language.
• Excellent verbal and written communication skills.
• Excellent customer service skills
• 3-5 years of clinical experience required
• RN with current unrestricted state licensure required.

Nice To Haves

• Managed Care experience preferred

Responsibilities

• Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units.
• Ensure timely, customer focused response to appeals, complaints and grievance.
• Identify trends and emerging issues and report and recommend solutions.
• Responsible for the review and resolution of clinical documentation, clinical complaints and 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.
• Reviews complaint/appeal requests of all clinical and benefit documentation.
• Considers all previous information as well as any additional records/data presented to render a recommendation/review.
• Data gathering requires navigation through multiple system applications.
• Contacts the provider of record, vendors or internal Aetna departments to obtain additional information.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR).
• Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure and regulatory requirements are required to support the appeals review.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals are processed within requirements.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs.
• Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.

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: No Education Listed