Appeals Nurse Consultant

Job not on LinkedIn

🕒 6 days ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $54.1k - $116.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 12%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Intake, investigate, and resolve appeals, complaints, and grievances for all products • Coordinate responses from multiple business units • Review and resolve clinical documentation, clinical complaints, and appeals • Review clinical records, interpret data, and apply clinical criteria and policies • Coordinate clinical resolution with internal and external clinicians • Review complaint and appeal requests involving clinical and benefit documentation • Gather data across multiple system applications • Contact providers, vendors, and internal Aetna departments for additional information • Apply review requirements and ensure specialty-matched practitioner review • Apply regulatory and accreditation standards to process appeals within required timelines • Condense complex information into clear and precise clinical summaries • Coordinate appeals with members, authorized representatives, providers, regulators, consultants, and other participants • Support fair hearings, state-mandated reviews, and appeal panel hearings • Report findings to team leaders and supervisors • Respond to rebuttal issues and recommend process improvements • Identify and report trends and emerging issues and provide input on potential solutions

🎯 Requirements

• Must live in Kentucky, United States • Requires an unrestricted active nursing license • RN with current unrestricted state licensure required • 3–5 years of clinical experience required • 3–5 years of Behavioral Health Experience • Experience in reading or researching benefit language • Excellent verbal and written communication skills • Excellent customer service skills • Managed Care experience preferred • Ability to navigate multiple system applications • Knowledge of complex delegation arrangements, coding logic, member and provider contracts, clinical criteria, benefit plan structure, and regulatory requirements

🏖️ Benefits

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

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