Appeals Nurse Consultant

Job not on LinkedIn

🔥 28 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $66.6k - $142.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Request and research submitted provider clinical information to support case review and determination processes • Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and supplemental policies • Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations using pre-approved workflows • Navigate multiple computer systems and applications to process cases accurately, compliantly, and on time • Collaborate with administrative coordinators, clinical nurse consultants, Medical Directors, Project Management, Medicare Appeals Analysts, Data Science, and other departments • Review UM outpatient appeals involving denied procedures, imaging, and medications requiring prior authorization • Review UM inpatient appeals involving hospital, readmission, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays • Evaluate down-coded claims and DRG assignments using medical records, coding guidelines, and clinical guidelines • Review coding appeals for denied claims and provide evidence-based recommendations • Conduct MPO clinical reviews for claim denials, including CCR and SIU cases • Work independently in a virtual team environment while performing sedentary computer-based duties, data entry, typing, and use of standardized templates

🎯 Requirements

• 3-5 years of experience as a Registered Nurse • Minimum 3+ years of clinical/hospital nursing experience • Registered Nurse associate’s degree or Diploma RN required • Active RN State License Required • 1+ years in Medicare Utilization Management, case review, or prior authorization preferred • Utilization Management, Managed Care, or Appeals experience preferred • Coding experience preferred • Pre-Authorization experience preferred • Ability to apply CMS guidelines, regulatory requirements, and applicable supplemental policies • Clinical proficiency and ability to consistently apply clinical and regulatory standards in decision-making

🏖️ 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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