Appeals Nurse Consultant (Remote)

At CVS Health, we are committed to helping people on their path to better health. We provide a wide range of services, from traditional retail pharmacy offerings to innovative healthcare solutions. As a leading healthcare company, we strive to create an environment that is inclusive, diverse, and patient-centered.

Position Overview:
We are currently seeking an experienced and dedicated Appeals Nurse Consultant to join our team. This is a remote position that will allow you to work from the comfort of your own home while making a significant impact in the lives of our members. As an Appeals Nurse Consultant, you will be responsible for reviewing and making decisions regarding complex medical appeals and denials, ensuring that each case is handled with care, thoroughness, and accuracy.

Key Responsibilities:

Conduct thorough reviews of clinical information and medical records to determine the appropriateness of services provided.
Evaluate clinical appeals and provide guidance on denials, ensuring compliance with regulatory and company guidelines.
Collaborate with providers, members, and interdisciplinary teams to resolve clinical issues.
Ensure accurate and timely documentation of all decisions and recommendations.
Assist in the development and maintenance of clinical appeal protocols and procedures.
Stay updated on relevant healthcare regulations, policies, and best practices.
Provide clinical expertise and support in the development of appeals strategies and interventions.

Required Qualifications:

Active Registered Nurse (RN) license in good standing.
At least 3 years of clinical nursing experience, with a focus on case management or clinical appeals.
Experience with insurance verification, utilization review, and healthcare claims processing.
Strong knowledge of medical terminology, procedures, and policies.
Excellent communication and interpersonal skills to work effectively with a variety of stakeholders.
Strong attention to detail and critical thinking abilities.

Preferred Qualifications:

Experience in an appeals, utilization review, or case management role in a healthcare setting.
Knowledge of healthcare regulations, including CMS guidelines, HIPAA, and ACA.
Familiarity with ICD-10 and CPT coding.

What We Offer:

Competitive salary and benefits package, including health insurance, 401(k), and paid time off.
Opportunities for professional growth and development.
A collaborative and supportive work environment.
Flexibility to work from home.

If you are a skilled Registered Nurse with a passion for helping others and a strong background in clinical appeals, we would love to hear from you. Apply today to join CVS Health and make a difference in the healthcare industry.