Appeals Nurse Consultant

Job not on LinkedIn

🔥 4 minutes ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $54.1k - $116.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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 across products • Coordinate responses from multiple business units • Review and resolve clinical documentation, clinical complaints, and appeals • Interpret clinical records and apply clinical criteria and policies in line with regulatory and accreditation requirements • Coordinate clinical resolution with internal and external clinician support • Review clinical and benefit documentation and render recommendations • 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 • Process appeals in accordance with regulatory and accreditation standards • Condense complex information into clear clinical summaries • Coordinate appeals with members, representatives, providers, regulators, consultants, and other participants • Report findings to team leaders and supervisors, respond to rebuttal issues, and recommend improvements • Identify trends and emerging issues and provide input on potential solutions

🎯 Requirements

• Must live in Kentucky, United States • 3–5 years of clinical experience • 3–5 years of Behavioral Health Experience • Experience in reading or researching benefit language • Excellent verbal and written communication skills • Excellent customer service skills • RN with current unrestricted state licensure required • 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 eligibility

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