Appeals Nurse Consultant

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🔥 1 hour ago

🦌 Connecticut, Ohio – Remote

🦌 Connecticut – Remote 🏈 Ohio – Remote

💵 $60.5k - $129.6k / 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

• Responsible for the review and resolution of clinical appeals. • Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements. • Independently coordinates the clinical resolution with internal/external clinician support as required. • This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals. • This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).

🎯 Requirements

• Must have active and unrestricted RN licensure in state of residence. • 3+ years clinical experience. • Appeals, Managed Care, or Utilization Review experience preferred. • Proficiency with computer skills including navigating multiple systems. • Exceptional communication skills. • Time efficient, highly organized, and ability to multitask. • Associate's Degree minimum.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package