Appeals Nurse Consultant (Remote)

CVS Health; United States; Remote; USD 54.000 - 117.000; Vollzeit

Benefits dieser Stelle

Medical, dental, and vision coverage

Zusammenfassung

CVS Health is seeking a dedicated Appeals Nurse Consultant to join our remote team. You will apply sound clinical judgment and regulatory knowledge to ensure fair resolution of clinical appeals. This full-time, 100% remote position features standard hours and occasional on-call coverage.

Responsibilities include reviewing documentation, interpreting data from records, and coordinating with internal/external clinicians. Prior appeals or utilization review experience is preferred.

Qualifikationen

• Active RN licensure in state of residence.
• 3+ years clinical experience.

Aufgaben

• Review and resolve clinical appeals.
• Interpret data from clinical records to apply criteria and policies per regulatory requirements.
• Coordinate clinical resolution with internal/external clinician support.
• Support UM (including expedited), MPO, Coding, or Behavioral Health appeals as needed.
• Work full-time remotely with standard hours, Mon-Fri 8:00 AM–5:00 PM (local time).
• Occasional weekend and holiday on-call coverage may be required.

Kenntnisse

Nursing

Communication

Multitasking

Ausbildung

Associate's Degree

Tools

Jobbeschreibung

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 ourselvesaccountable 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

CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Key Responsibilities

• 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 for member and provider issues.
• 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).
• Occasional weekend and holiday on-call coverage may be required.

Remote Work Expectations

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required Qualifications

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.

Preferred Qualifications

• Appeals, Managed Care, or Utilization Review experience.
• Proficiency with computer skills including navigating multiple systems.
• Exceptional communication skills.
• Time efficient, highly organized, and ability to multitask.

Education

• Associate's Degree minimum.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $54,095.00 - $116,760.00

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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: 11/13/2026

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