Appeals Nurse Consultant - Remote

CVS Health•Work At Home-Connecticut, CT

1d•$66,575 - $142,576•Remote

About The Position

The Medicare PAR Provider Appeals Nurse Consultant manages PAR Provider post-service payment disputes and appeals. The team includes administrative coordinators and clinical nurse consultants and associates who provide timely reviews of provider disputes and appeals. Reviews may focus on Medical Policy Operations (MPO), Coding, DRG Assignment, Utilization Management (UM) Inpatient, or UM Outpatient. The role collaborates with other departments, Medical Directors, Project Management, the Medicare Appeals Analyst team, and the Data Science team. This is a full-time remote position that can be performed from home anywhere in the United States. Hours are Monday through Friday, 8 a.m. to 5 p.m. in the employee’s time zone of residence. The position is a fast-paced, sedentary role involving extended computer use, standardized templates, data entry, and typing. Responsibilities vary by review focus. UM Outpatient nurses review appeals of denied procedures, imaging, and medications requiring prior authorization, applying tiered CMS and Aetna medical-necessity criteria. UM Inpatient nurses review appeals of denied inpatient stays, including hospital, readmission, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays. DRG Appeals Nurses evaluate down-coded claims using medical records and coding and clinical guidelines, and prepare cases for Medical Director review. Coding Appeals Nurses evaluate clinical documentation and coding for denied claims and provide evidence-based recommendations. MPO Appeals Nurses review claim denials, including CCR and SIU cases, to determine whether cases should be overturned or prepared for Medical Director review.

Requirements

3–5 years of experience as a Registered Nurse.
At least 3 years of clinical or hospital nursing experience.
Active RN state license.
Associate degree in nursing or a Diploma RN.

Nice To Haves

BSN preferred.
At least 1 year of experience in Medicare Utilization Management, case review, or prior authorization.
Utilization Management, managed care, or appeals experience.
Coding experience.
Pre-authorization experience.

Responsibilities

Request and research submitted provider clinical information to support case review and determination processes.
Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies.
Prepare comprehensive nurse summaries for Medical Director evaluation or finalize appeal determinations in accordance with pre-approved workflows.
Navigate and manage multiple computer systems and applications to process cases accurately, compliantly, and on time.
Work independently while contributing to teamwork and collaboration in a virtual environment.
Apply clinical and regulatory standards consistently in decision-making.
Review denied outpatient procedures, imaging, and medications requiring prior authorization for medical necessity.
Review appeals of denied inpatient stays by analyzing medical records and appeal criteria.
Evaluate down-coded claims to determine whether the assigned Diagnosis Related Group is supported, and prepare cases for Medical Director review.
Review clinical documentation and coding for denied claims and provide clear, evidence-based recommendations.
Conduct clinical reviews of claim denials, including CCR and SIU cases, to determine whether cases should be overturned or prepared for Medical Director review.