Utilization Management Appeals Nurse Consultant (Remote)

CVS Health

1d•Remote

About The Position

American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. They provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. The Appeals Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical records and applying clinical guidelines for the Utilization Management group. This RN must be licensed in the state that they reside, with strong experience in utilization review, coding, and managed care.

Requirements

Active, unrestricted RN license in your state of residence.
3+ years Utilization Management or Utilization Review experience.
1+ year(s) of experience demonstrating knowledge of clinical and medical policy, Milliman Care Guidelines (MCG), InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience.
1+ year(s) of experience demonstrating knowledge of International Classification of Diseases (ICD-9), Current Procedural Terminology (CPT) coding and Healthcare Common Procedure Coding (HCPC).

Nice To Haves

Multistate/compact licensure privileges.
1+ year(s) of Appeals experience in Utilization Management.

Responsibilities

Administers review and resolution of clinical complaints and appeals.
Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers.
Coordinates clinical resolutions with internal and external support areas.