Appeals Nurse Consultant

Job 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
• Work full-time in a telework arrangement

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 preferred
• Exceptional communication skills preferred
• Time efficient, highly organized, and ability to multitask preferred
• Dedicated workspace free of interruptions
• Separate care arrangements for dependents during work hours
• Availability for standard Monday–Friday, 8:00 AM to 5:00 PM local-time hours
• Occasional weekend and holiday on-call coverage may be required

Benefits:

• CVS Health bonus, commission or short-term incentive program in addition to base pay
• 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