Appeals Nurse Consultant (Remote)

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.

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.

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  Responsible for the review and resolution of clinical appeals.

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  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.

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  Independently coordinates the clinical resolution with internal/external clinician support as required.

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  This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.

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  This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).

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  Occasional weekend and holiday on-call coverage may be required.

• 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.

• Must have active and unrestricted RN licensure in state of residence.

• 3+ years clinical experience.

• 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.

• Associate's Degree minimum.

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.