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Appeals Nurse Consultant

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States

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Category:
Nursing

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Contract Type:
Not provided

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Salary:

Not provided
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Job Description:

This is a full-time telework position. Hours for this role are Monday-Friday 8a-5p in time zone of residence with the possibility of occasional on-call weekend requirements. Position Summary: Responsible for the review and resolution of clinical appeals. 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. Independently coordinates the clinical resolution with internal/external clinician support as required. This position may support UM, MPO, Coding, or Behavioral Health appeals.

Job Responsibility:

  • Responsible for the review and resolution of clinical appeals
  • 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
  • Independently coordinates the clinical resolution with internal/external clinician support as required

Requirements:

  • Must have active and unrestricted RN licensure in state of residence
  • 3+ years clinical experience

Nice to have:

  • Appeals Experience
  • Managed Care Experience
  • Utilization review experience
  • Proficiency with computer skills including navigating multiple systems
  • Exceptional communication skills
  • Time efficient, highly organized, and ability to multitask

Additional Information:

Job Posted:
May 14, 2025

Employment Type:
Fulltime
Work Type:
Remote work
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