Appeals Nurse Consultant

Job not on LinkedIn

🔥 25 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 applicable supplemental policies • Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations in accordance with pre-approved workflows • Navigate and manage multiple computer systems and applications for timely, accurate, and compliant case processing • Work independently while contributing to teamwork and collaboration in a virtual environment • Perform extended computer use, standardized template utilization, data entry, and typing tasks • Review denied outpatient procedures, imaging, and medications for medical necessity based on CMS and Aetna criteria • Review denied inpatient stays by analyzing medical records and appeals criteria • Evaluate down-coded claims and determine whether assigned DRGs are supported by medical records, coding, and clinical guidelines • Review clinical documentation and coding for denied claims and provide evidence-based recommendations • Conduct clinical reviews for claim denials, including CCR and SIU cases, determining whether cases should be overturned or prepared for medical director review • Collaborate with departments, Medical Directors, Project Management, Medicare Appeals Analysts, and Data Science teams

🎯 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

🏖️ Benefits

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

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