Appeals Nurse Consultant

Job Description:

  • Review and resolve clinical appeals
  • Review documentation and interpret data from clinical records
  • Apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements
  • Address member and provider issues
  • Coordinate clinical resolution independently with internal and external clinician support as required
  • Support UM, including expedited appeals, MPO, Coding, or Behavioral Health appeals
  • Work full-time in a telework arrangement

Requirements:

  • Active and unrestricted RN licensure in state of residence
  • 3+ years clinical experience
  • Associate's Degree minimum
  • Appeals, Managed Care, or Utilization Review experience preferred
  • Proficiency with computer skills including navigating multiple systems preferred
  • Exceptional communication skills preferred
  • Time efficient, highly organized, and ability to multitask preferred
  • Dedicated workspace free of interruptions
  • Separate care arrangements for dependents during work hours
  • Availability for standard Monday–Friday, 8:00 AM to 5:00 PM local-time hours
  • Occasional weekend and holiday on-call coverage may be required

Benefits:

  • CVS Health bonus, commission or short-term incentive program in addition to base pay
  • Medical coverage
  • Dental coverage
  • Vision coverage
  • Paid time off
  • Retirement savings options
  • Wellness programs
  • Other resources supporting physical, emotional, and financial well-being, based on eligibility
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