Appeals Nurse Consultant- MUST live in KY

CVS Health; Kentucky; Ibrido; USD 54.000 - 117.000; Tempo pieno

Descrizione del lavoro

CVS Health is hiring for a role focused on intake, investigation and resolution of appeals, complaints and grievances across products. You will coordinate with clinical staff and providers to apply clinical criteria, ensure timely responses, and identify trends to drive improvements.

Must hold an active nursing license and have behavioral health experience. The role emphasizes collaboration, compliance with regulations, and delivering clear, clinically grounded recommendations across multiple

Competenze

• Experience reading or researching benefit language.
• Excellent verbal and written communication skills.
• Excellent customer service with healthcare focus.

Mansioni

• Intake, investigation and resolution of appeals and grievances.
• Coordinate with clinicians, providers and internal teams to resolve cases.
• Identify trends and report findings to improve processes.

Conoscenze

Verbal communication

Written communication

Customer service

Behavioral health experience

Formazione

RN licensure

Descrizione del lavoro

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions. In particular responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an unrestricted active nursing license. Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review. Data gathering requires navigation through multiple system applications. Contacts the provider of record, vendors or internal Aetna departments to obtain additional information. Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure and regulatory requirements are required to support the appeals review. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals are processed within requirements. Condenses complex information into a clear and precise clinical picture while working independently. Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. Identifies trends and emerging issues and reports on and gives input on potential solutions.

Required Qualifications

• Experience in reading or researching benefit language.
• Excellent verbal and written communication skills.
• Excellent customer service skills -3-5 years of clinical experience required MUST have 3-5 years of Behavioral Health Experience

Preferred Qualifications

• Managed Care experience preferred Education RN with current unrestricted state licensure required.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range

The typical pay range for this role is: $54,095.00 - $116,760.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Great benefits for great people. We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/31/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.