Appeals Nurse Consultant (Remote)

The Appeals Nurse Consultant position is responsible for processing the medical neces

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sity of Medicare Part C appeals from both members and providers. This role is considered a production role and remains as part of the Nurse Appeal Consultant job code. Primary duties may include, but are not limited to: requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare Guidelines, navigate through multiple computer system applications in a fast paced department. Must work independently as well as in a team environment while working remotely.  The Medicare Clinical Appeals Team C Member/Non-Par Team operates 7 days per week, 365 days per year. This position requires some weekends and holidays on a scheduled rotation.

  • Must be comfortable in a fast-paced environment
  • Ability to meet deadlines in a deadline intensive environment
  • High level of adaptability and willingness to embrace change in a fast-paced, demanding environment
  • Demonstrates a solid understanding of all workflows, policies, and procedures
  • Must have ability to use hands for repetitive typing, input data, copy, speak clearly, view computer monitors
  • Responsible for reviewing & preparing appeals submitted by patients or healthcare providers for MD review
  • Collaborate with internal business partners and external entities to gather and evaluate necessary information
  • Provide written recommendations or decisions based on available clinical, ensuring adherence to CVS Health and Medicare guidelines.
  • Attend and participate in department meetings.
  • Meticulous attention to detail with accurate documentation
  • Prepare templates using structured decision-making frameworks extrapolating pertinent clinical information from patient records
  • Proficiency with computer skills including Microsoft Outlook, Windows, navigating multiple systems and keyboarding
  • Time efficient and highly organized
  • Exceptional verbal and written communication skills
  • Highly attentive to detail while taking initiative staying on top of a variety of tasks simultaneously

Required Qualifications

  • Active and unrestricted RN licensure in state of residence
  • 3+ years of clinical experience

Preferred Qualifications

  • Utilization Review experience
  • Medicare experience
  • Appeals experience

Education

  • Associate’s Degree or RN diploma required

Pay Range

The typical pay range for this role is:

$61,360.00 – $132,600.00

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.

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