Appeals Nurse Consultant Job at CVS Health

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Discharge Co-ordinator

As a key member of the financial team, the Discharge Co-ordinator will work with...

Location

Ireland

Salary:

Not provided

Blackrock Health Hermitage Clinic

Expiration Date

Until further notice

Requirements

2 years working in a healthcare setting
Working in a team environment
Experience in dealing with patients/customers
Self-starter
High attention to detail
Ability to analyse high volumes of information
Advanced knowledge of MS Excel
Relationship building with internal and external personnel
Team player with the ability to work on own initiative
Able to prioritise and multi-task

Job Responsibility

Complete early assessment of patients’ medical, social, and functional needs
Identify potential barriers to discharge and plan solutions proactively
Assess suitability for home, rehabilitation, or step-down facilities
Attend ward rounds or MDT meetings to review progress and confirm discharge goals
Communicate and update discharge plans with consultants, nurses, therapists, and social workers
Highlight patients requiring complex discharge planning
Provide clear information about discharge timelines, expectations, and required supports
Educate patients/families on medications, follow-up appointments, and self-care needs
Facilitate shared decision-making for discharge destinations
Communicate the potential financial exposure for each admission to the Head of Finance Operations, patient and their nominated representatives

Field Case Manager

Our team members are at the heart of everything we do. At Cencora, we are united...

Location

Canada , Windsor

Salary:

67000.00 - 102960.00 CAD / Year

Cencora

Expiration Date

Until further notice

Requirements

A Bachelor’s degree in health care or a related discipline
Requires a minimum five (5) years, in the healthcare, pharmaceutical or insurance industry or related experience
Case management experience preferred
Available to travel within an assigned territory, some overnight travel may be required
Valid Driver’s License, current auto insurance policy and access to reliable transportation, for regional travel
Experience and background in various therapeutic areas is an asset
Background in business administration (pharmaceutical) sales and marketing an asset
Knowledge of private and public reimbursement structure, systems, and process
Experience with reimbursement navigation, special authorization, appeals process and conducting field-based reimbursement support and consultation
Strong analytical skills including interpretation of regulation and legislation

Job Responsibility

Practice Management: Customize program elements to meet the needs of assigned prescribing physicians
Review patient status and assist the prescribing physician to complete patient enrolment, prepare payer forms to access public or private coverage by reviewing patient charts, documenting previous therapies and tests in order to complete the payer forms
Identify obstacles to obtaining coverage and channel this information to the Program Manager
Develop strong working relationships with physicians and physician office staff, providing additional office support to ensure smooth maintenance of patients enrolled in the program as needed
Proactively provide assistance to resolve issues with regards to assigned physicians
Provide training to physicians and clinics on program and new initiatives approved by the manufacturer
Acts as a liaison and provide ongoing feedback to the Program Manager based on observations in the field and feedback from physicians as it pertains to quality of services, training, and other areas of importance
Complete all relevant reports (program specific reports, expenses, etc.) as per specified timelines and as per required standards.
Patient Support (Based on program design some Field Case Managers may have limited or no patient interactions): Welcome each patient to the program and capture required patient information
Provide reimbursement payer guidelines to patients and physicians

What we offer

We provide compensation, benefits, and resources that enable a highly inclusive culture and support our team members’ ability to live with purpose every day. In addition to traditional offerings like medical, dental, and vision care, we also provide a comprehensive suite of benefits that focus on the physical, emotional, financial, and social aspects of wellness. This encompasses support for working families, which may include backup dependent care, adoption assistance, infertility coverage, family building support, behavioral health solutions, paid parental leave, and paid caregiver leave. To encourage your personal growth, we also offer a variety of training programs, professional development resources, and opportunities to participate in mentorship programs, employee resource groups, volunteer activities, and much more.

Fulltime

Field Case Manager

This is a 12-Month Contract role. Our team members are at the heart of everythin...

Location

Canada , Edmonton

Salary:

Not provided

Cencora

Expiration Date

Until further notice

Requirements

A Bachelor’s degree in health care or a related discipline
Requires a minimum five (5) years, in the healthcare, pharmaceutical or insurance industry or related experience
Case management experience preferred
Available to travel within an assigned territory, some overnight travel may be required
Valid Driver’s License, current auto insurance policy and access to reliable transportation, for regional travel
Experience and background in various therapeutic areas is an asset
Background in business administration (pharmaceutical) sales and marketing an asset
Knowledge of private and public reimbursement structure, systems, and process
Experience with reimbursement navigation, special authorization, appeals process and conducting field-based reimbursement support and consultation
Strong analytical skills including interpretation of regulation and legislation

Job Responsibility

Customize program elements to meet the needs of assigned prescribing physicians
Review patient status and assist the prescribing physician to complete patient enrolment, prepare payer forms to access public or private coverage by reviewing patient charts, documenting previous therapies and tests in order to complete the payer forms
Identify obstacles to obtaining coverage and channel this information to the Program Manager
Develop strong working relationships with physicians and physician office staff, providing additional office support to ensure smooth maintenance of patients enrolled in the program as needed
Proactively provide assistance to resolve issues with regards to assigned physicians
Provide training to physicians and clinics on program and new initiatives approved by the manufacturer
Acts as a liaison and provide ongoing feedback to the Program Manager based on observations in the field and feedback from physicians as it pertains to quality of services, training, and other areas of importance
Complete all relevant reports (program specific reports, expenses, etc.) as per specified timelines and as per required standards
Welcome each patient to the program and capture required patient information
Provide reimbursement payer guidelines to patients and physicians

What we offer

We provide compensation, benefits, and resources that enable a highly inclusive culture and support our team members’ ability to live with purpose every day. In addition to traditional offerings like medical, dental, and vision care, we also provide a comprehensive suite of benefits that focus on the physical, emotional, financial, and social aspects of wellness. This encompasses support for working families, which may include backup dependent care, adoption assistance, infertility coverage, family building support, behavioral health solutions, paid parental leave, and paid caregiver leave. To encourage your personal growth, we also offer a variety of training programs, professional development resources, and opportunities to participate in mentorship programs, employee resource groups, volunteer activities, and much more.

Fulltime

RN Regulatory Program Coordinator

The Regulatory Program Coordinator serves as the expert resource on regulatory/a...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Bachelor’s degree in nursing from an accredited institution
Five (5) years nursing experience in a hospital setting
Current RN licensure permitting work in the state of Arizona
Knowledge of regulatory requirements (TJC and CMS)
Knowledge of the accreditation process
Knowledge of survey preparation and required follow-up activities
Skill in written and oral communications
Skill in conducting mock regulatory surveys using the tracer methodology
Ability to interpret, prepare, and present reports to management in both written and oral formats
Ability to make presentations, design and provide training/education to staff and management

Job Responsibility

Serves as the expert resource on regulatory/accreditation and licensure standards and expectations for compliance
Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the organization
Guide the development of policy and guidelines as they relate to the hospital and compliance with regulatory and accreditation guidelines
Assist in the interpretation of these policies
Provides central expertise regarding accreditation and licensure standards
Identify, plan for, communicate, monitor, and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the organization
Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys
Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission
Identify areas of vulnerability and assist area leaders in developing corrective action plans
Identify and communicate areas of success to celebrate and encourage promotion of best practices

Fulltime

New

Sales Consultant

We are looking for a Casual Sales Consultant to join our CALVIN KLEIN team at IN...

Location

Australia , Indooroopilly

Salary:

Not provided

Calvin Klein

Expiration Date

Until further notice

Requirements

Excellent communication skills
Vibrant, energetic and authentic with a positive "can do" attitude
Ability to multi-task in a fast-paced environment
Impeccable grooming and personal presentation

What we offer

Clothing Allowance
Generous employee discounts on all brands (Calvin Klein, Tommy Hilfiger & Van Heusen)
Recruitment Referral Bonus
Access to Employee Assistance program
Corporate discount with Medibank
Annual Flu Shot voucher
Strong focus on Corporate Responsibility
Inclusive, diverse, and equal opportunity employer
Training, development, and career opportunities
Paid Parental Leave as per Company Policy

Parttime

New

IT Support Specialist

A premier, boutique international law firm is seeking an IT Support Specialist f...

Location

United States , New York City

Salary:

75000.00 - 90000.00 USD / Year

Strategic Employment Partners

Expiration Date

Until further notice

Requirements

Associate’s degree in Information Technology or a related field
2+ years of relevant IT support experience, preferably within a professional services environment (Legal, Finance, or Consulting)
Hands-on experience with Windows 11, Microsoft 365, and mobile device management (Intune/iOS)

Job Responsibility

Resolve hardware and software issues for local and remote staff, including mobile devices and firm computers
Maintain conference room A/V systems for high-level meetings and assist with LAN/WLAN troubleshooting
Prepare and deploy equipment for new hires and manage the onboarding process from a technology standpoint
Help maintain the firm’s inventory of hardware and software licenses
Support firmwide technology initiatives and participate in occasional after-hours maintenance to ensure peak system performance

What we offer

Comprehensive Health, Dental, and Vision insurance
401(k) retirement plan
Firm-sponsored Life and Disability insurance
Dedicated well-being programs and a supportive office culture

Fulltime

New

Maternity Support Worker - Community

The Band 3 Maternity Support Worker (MSW) will provide essential support to the ...

Location

United Kingdom , Swindon

Salary:

24937.00 - 26598.00 GBP / Year

Great Western Hospitals NHS Foundation Trust

Expiration Date

March 06, 2026

Requirements

NVQ 2 in healthcare or equivalent
Committed to within the first 12 months undertaking trust training program, care certificate including some private study, and completing competency framework
Owner and Car driver is essential
Training and /or competency in the following: Patient vital sign observations, Venepuncture, Neonatal observations
Significant and relevant work/social experience within a health care environment, which has utilised skills and knowledge that could be of benefit to the post
Previous experience of working with members of the public
Previous experience of working within an NHS setting in the UK

Job Responsibility

Postnatal Support: Provide practical and emotional support to parents and their newborn babies, assisting with feeding, infant care, and adjustment to parenthood
Newborn Screening: Undertake screening procedures on newborn babies, including hearing tests, metabolic screening, and other routine checks in line with Trust policies
Blood Clinics: Organise and run blood collection clinics (venepuncture/phlebotomy) for mothers and babies, maintaining accurate records and following infection control procedures
Parent Education: Participate in parentcraft and antenatal/postnatal education sessions, supporting teaching and learning activities for parents
Home Visits: Undertake postnatal home visits as a lone worker, providing assessment, guidance, and support while adhering to lone-working and safety protocols
Administrative Duties: Maintain accurate and timely documentation, ensure compliance with data protection and governance standards, and contribute to service reporting as required
Team Collaboration: Work closely with midwives, health visitors, and the wider multidisciplinary team to ensure continuity of care and support service delivery
Clinical Support: Assist midwives with routine maternity care, including monitoring, observations, and basic care for women and babies
Support clinical procedures under supervision, including venepuncture and phlebotomy (following training and competency assessment)
Ensure timely escalation of clinical concerns to the appropriate midwife

Parttime

!

Appeals Nurse Consultant

CVS Health

Location:
United States

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
May 14, 2025

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Appeals Nurse Consultant