Appeals Nurse Consultant

Job not on LinkedIn

🔥 13 hours ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $54.1k - $116.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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

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

• Intake, investigate, and resolve appeals, complaints, and grievances across products • Review and resolve clinical documentation, clinical complaints, and appeals • Review clinical records, interpret data, and apply clinical criteria and policies in line with regulatory and accreditation requirements • Coordinate clinical resolutions with internal and external clinician support • Gather data using multiple system applications • Contact providers, vendors, and internal Aetna departments for additional information • Apply review requirements to ensure cases are reviewed by practitioners with appropriate clinical expertise • Process appeals in accordance with regulatory and accreditation standards • Condense complex information into clear and precise clinical summaries • Coordinate appeals with members, authorized representatives, providers, regulators, consultants, and other participants • Report findings to team leaders and supervisors, respond to rebuttal issues, and recommend improvements • Identify and report trends and emerging issues and provide input on potential solutions

🎯 Requirements

• Must live in KY • Current unrestricted state RN licensure required • 3–5 years of clinical experience required • 3–5 years of Behavioral Health Experience required • Experience in reading or researching benefit language • Excellent verbal and written communication skills • Excellent customer service skills • Knowledge of complex delegation arrangements, coding logic, member and provider contracts, clinical criteria, benefit plan structure, and regulatory requirements • Managed Care experience preferred

🏖️ 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