Utilization Management Appeals Nurse Consultant (Remote)

CVS Health; Town of Woodstock (NY); Remote; USD 54,000 - 117,000; Full time

Job summary

A leading health solutions company is seeking an Appeals Nurse Consultant for a remote role. Responsibilities include resolving clinical complaints and applying clinical guidelines in Utilization Management. Candidates should have 3+ years of relevant experiences, a strong clinical background, and an active RN license. The role offers a competitive salary and comprehensive benefits for employees.

Benefits

Affordable medical plans

401(k) plan with company matching

Employee stock purchase plan

Wellness programs

Qualifications

• 3+ years of Utilization Management or Utilization Review experience.
• Active, unrestricted RN license in state of residence.
• Knowledge of clinical guidelines and state regulatory requirements.

Responsibilities

• Resolve clinical complaints and appeals by reviewing medical records.
• Interpret data and apply clinical criteria for compliance.
• Coordinate clinical resolutions with support areas.

Skills

Utilization Management experience

ICD-9 and CPT coding knowledge

Clinical nursing experience

Analytical skills

Education

Associate's degree in nursing (RN)

Job description

Overview

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate.

Position Information

Schedule: Monday–Friday 9:30am-5:30pm EST. Hours (shift times may vary with possible weekends based on business needs).

Location: 100% Remote (U.S. only)

About Us

American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team.

Position Summary

The Appeals Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical records and applying clinical guidelines for the Utilization Management group. This RN must be licensed in the state that they reside, with strong experience in utilization review, coding, and managed care.

Key Responsibilities

• Administers review and resolution of clinical complaints and appeals.
• Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers.
• Coordinates clinical resolutions with internal and external support areas.

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

• 3+ years Utilization Management or Utilization Review experience.
• 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience.
• 1+ year(s) of experience demonstrating knowledge of ICD-9, CPT coding and HCPC.
• 1+ year(s) of experience demonstrating knowledge of clinical and medical policy, Milliman Care Guidelines (MCG), InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges.

Preferred Qualifications

• 1+ year(s) of Appeals experience in Utilization Management.

Education

• Associate's degree in nursing (RN) required, BSN preferred.

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.

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.

Benefits

Great Benefits For Great People

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 11/10/2025

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