Appeals Nurse Consultant

CVS Health • Hartford, CT

6d • 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.
Position Summary
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.
This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
Occasional weekend and holiday on-call coverage may be 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.
• 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

• 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