Nurse Consultant Jobs

About The Position

Requirements

• Candidate must have active and unrestricted Registered Nurse (RN) License in their state of residence
• Candidate must be willing to obtain a Compact Registered Nurse (RN) License within 3 months of hire
• 3+ years of Medicare/Medicaid Appeal Processing/Review Experience
• Associate's Degree in Nursing OR Nursing Diploma (REQUIRED)
• Active and unrestricted Registered Nurse (RN) License in their state of residence
• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
• Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Openness to learning new skills in the future as the workplace environment evolves

Nice To Haves

• Utilization management or appeals experience
• Bachelor's Degree (PREFERRED)

Responsibilities

• Acts as a top-level specialist to implement best in class policies, plans, and procedures in support of the Appeals area objectives.
• Executes review of all clinical and benefit documentation for complaint and appeal requests (for integrated Medicare/Medicaid plans)
• Develops strategy for review requirements to assure case reviews are overseen by practitioners with relevant clinical expertise.
• Applies advanced knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements to support appeals review.
• Ensures appeal process compliance with regulatory and accreditation standards.
• Counsels with members, representatives, providers, regulators, and participants on the appeals process in compliance with state regulation and benefit plan designs.
• Coaches and trains junior colleagues in techniques, processes, and responsibilities.

Benefits

• medical
• dental
• vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility