Remote Nurse Appeals Consultant Clinical Judgement

4062 Aetna Resources, LLC; Connecticut; Hybrid; USD 67,000 - 143,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a dedicated Appeals Nurse Consultant to join our remote team. The role focuses on fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Responsibilities include reviewing appeals, interpreting clinical data, and coordinating resolutions with clinicians. This is a full-time telework position with standard hours and possible on-call coverage. Benefits include a comprehensive package and performance bonuses.

Qualifications

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

Responsibilities

• Review and resolve clinical appeals per applicable criteria and policies.
• Review documentation and data from clinical records to apply regulatory and accreditation requirements.
• Coordinate clinical resolution with internal/external clinician support as needed.
• Support UM, MPO, Coding, or Behavioral Health appeals as required.

Skills

Communication skills

Clinical experience

multitasking

Computer literacy

Education

RN licensure

Associate's degree

Tools

Multiple systems navigation

Job description

CVS Health is seeking a dedicated Appeals Nurse Consultant to join our remote team. The role focuses on fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Responsibilities include reviewing appeals, interpreting clinical data, and coordinating resolutions with clinicians. This is a full-time telework position with standard hours and possible on-call coverage. Benefits include a comprehensive package and performance bonuses.