Appeals Nurse Consultant

Job not on LinkedIn

🔥 0 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $66.6k - $142.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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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

• Review and resolve clinical appeals • Review documentation and interpret data from clinical records • Apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements • Address member and provider issues • Coordinate clinical resolution independently with internal and external clinician support as required • Support UM, including expedited appeals, MPO, Coding, or Behavioral Health appeals

🎯 Requirements

• Active and unrestricted RN licensure in state of residence • 3+ years clinical experience • Associate's Degree minimum • Appeals, Managed Care, or Utilization Review experience preferred • Proficiency with computer skills including navigating multiple systems • Exceptional communication skills • Time efficient, highly organized, and able to multitask • Dedicated workspace free of interruptions • Separate care arrangements for dependents during work hours • Ability to work Monday–Friday, 8:00 AM to 5:00 PM local time • Occasional weekend and holiday on-call coverage may be required

🏖️ 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 the base pay range