Appeals Nurse Consultant (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 clinical judgment and regulatory knowledge. The consultant reviews clinical documentation, applies appropriate criteria and policies, and coordinates clinical resolutions with internal or external clinician support as needed. The position may support UM (including expedited appeals), MPO, Coding, or Behavioral Health appeals. This is a 100% remote role with standard Monday–Friday hours of 8:00 AM to 5:00 PM local time; occasional weekend and holiday on-call coverage may be required. Candidates must have a dedicated workspace free of interruptions and separate care arrangements for dependents during work hours.
Requirements
- Active and unrestricted RN licensure in the state of residence.
- At least 3 years of clinical experience.
- Associate's degree or higher.
- Maintain a dedicated workspace free of interruptions.
- Arrange separate dependent care during work hours; continuous care responsibilities during shift times are not permitted.
Nice To Haves
- Experience in appeals, managed care, or utilization review.
- Computer proficiency, including navigating multiple systems.
- Exceptional communication skills.
- Time-efficient, highly organized, and able to multitask.
Responsibilities
- Review and resolve clinical appeals.
- Review documentation and interpret data from clinical records, applying appropriate clinical criteria and policies in accordance with regulatory and accreditation requirements for member and provider issues.
- Independently coordinate clinical resolutions with internal or external clinician support as required.
- Support UM (including expedited), MPO, Coding, or Behavioral Health appeals as assigned.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other resources, based on eligibility.
- Eligibility for a CVS Health bonus, commission, or short-term incentive program.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
