Appeals Nurse Consultant
New
C
CVS HealthHealthcare appeals
This is a full-time remote position working from home anywhere in the US., Monday–Friday, 8am–5pm in the time zone of residence.Full-TimeMiddle
Salary$66,575.00 - $142,576.00
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Job Details
- Experience
- 3-5 years of experience as a Registered Nurse; minimum 3+ years of clinical/hospital nursing experience.
Requirements
- Have 3–5 years of experience as a Registered Nurse.
- Have at least 3 years of clinical or hospital nursing experience.
- Hold an associate’s degree or Diploma RN.
- Maintain an active RN state license.
- A BSN is preferred.
- Experience in Medicare utilization management, case review, or prior authorization is preferred.
- Utilization management, managed care, or appeals experience is preferred.
- Coding experience is preferred.
Responsibilities
- Request and research submitted provider clinical information to support case reviews and determinations.
- Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies.
- Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations using pre-approved workflows.
- Review appeals involving utilization management, medical policy operations, coding, or DRG assignment as assigned.
- Navigate and manage multiple computer systems and applications to process cases accurately and on time.
- Use standardized templates and complete data entry and typing tasks during extended computer use.
- Work independently while collaborating with colleagues in a virtual environment.
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