Remote Appeals Nurse Consultant — Clinical Resolution Expert

CVS Health; Charleston (WV); Remote; USD 54,000 - 117,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Paid time off

Job summary

CVS Health invites applications for a remote Appeals Nurse Consultant. You will review and resolve clinical appeals using sound clinical judgment and regulatory knowledge, coordinating with clinicians as required.

The role is full-time, with standard hours Monday through Friday 8:00 AM–5:00 PM local time and occasional on-call coverage on weekends or holidays. Active RN licensure in state of residence and at least 3 years of clinical experience are required.

Qualifications

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.
• Experience in appeals, managed care or utilization review is preferred.
• Proficiency with computer skills including navigating multiple systems.
• Exceptional communication skills and strong time-management abilities.

Responsibilities

• Review and resolve clinical appeals.
• Interpret data from clinical records applying appropriate criteria and policies in line with regulatory requirements.
• Coordinate clinical resolution with internal/external clinician support as required.
• Support UM (including expedited), MPO, Coding, or Behavioral Health appeals as needed.
• Full-time remote role with standard hours Mon-Fri 8:00 AM–5:00 PM local time; occasional weekend/holiday on-call may be required.

Skills

RN licensure

Clinical experience

Appeals experience

Managed Care

Utilization Review

Computer skills

Communication skills

Multitasking

Education

Associate's Degree

Tools

Health IT systems

Job description

CVS Health invites applications for a remote Appeals Nurse Consultant. You will review and resolve clinical appeals using sound clinical judgment and regulatory knowledge, coordinating with clinicians as required.

The role is full-time, with standard hours Monday through Friday 8:00 AM–5:00 PM local time and occasional on-call coverage on weekends or holidays. Active RN licensure in state of residence and at least 3 years of clinical experience are required.