Senior Clinical Appeals Nurse Consultant - Remote

Join CVS Health and make a meaningful difference in the lives of our members as a Senior Clinical Appeals Nurse Consultant!

At CVS Health, our core purpose is to bring our heart to every moment of your health. We are committed to delivering enhanced, human-centric healthcare in a rapidly evolving world. Our brand, built on a foundation of heart, emphasizes that the way we deliver our services is just as important as the services themselves. We foster a work environment where every individual feels empowered to contribute to a culture of innovation and to develop solutions that make healthcare more personal, convenient, and affordable. We are seeking a highly skilled and compassionate Senior Clinical Appeals Nurse Consultant to join our dynamic remote team.

This is a full-time, remote position available to candidates throughout the United States, with standard business hours of Monday-Friday, 8:00 AM to 5:00 PM, in the candidate's local time zone. This role offers a competitive salary and a comprehensive benefits package. We are currently hiring and offer immediate start opportunities.

Position Overview

As a Senior Clinical Appeals Nurse Consultant, you will be a pivotal member of our Medicare Clinical Appeals team, responsible for the comprehensive review and resolution of clinical complaints and appeals for Medicare Part C members and providers. This is a critical production role that requires a deep understanding of clinical nursing practice, regulatory requirements, and appeals processes. You will leverage your expertise to ensure fair and accurate outcomes for our members while adhering to all applicable guidelines and policies. This position demands a proactive, detail-oriented individual who thrives in a fast-paced, remote environment.

Key Responsibilities

• Clinical Expertise & Appeals Review: Serve as a subject matter expert in clinical nursing, conducting thorough reviews of complex clinical and benefit documentation associated with member and provider appeals. This includes interpreting medical records, clinical guidelines, and coding logic to determine appropriate clinical criteria and policy application.
• Strategic Case Management: Develop and implement strategic approaches to appeal reviews, ensuring that cases are overseen by qualified clinical practitioners with relevant expertise. Proactively identify potential issues and collaborate with internal and external stakeholders to facilitate timely and effective resolutions.
• Regulatory & Compliance Adherence: Ensure that all appeal processes comply with federal and state regulatory requirements, accreditation standards, and internal policy guidelines. Stay abreast of changes in regulations and guidelines and translate them into practical application within the appeals process.
• Member & Stakeholder Communication: Counsel members, representatives, providers, regulators, and other relevant parties on the appeals process, ensuring clear and empathetic communication in compliance with state regulations and benefit plan designs.
• Mentorship & Training: Coach and train junior colleagues on appeals techniques, processes, and responsibilities, fostering a collaborative and supportive team environment. Share best practices and contribute to the development of standardized procedures.
• System Navigation & Data Management: Efficiently navigate multiple computer systems and applications to access and analyze relevant clinical and benefit information. Accurately document all review findings, recommendations, and resolutions.
• Process Improvement: Identify opportunities for process improvement within the appeals function, contributing to enhanced efficiency and effectiveness.
• Independent & Collaborative Work: Demonstrate the ability to work independently with minimal supervision while also collaborating effectively within a remote team environment.

Qualifications

Required Qualifications:

• Active and unrestricted Registered Nurse (RN) license in the state of primary residence.
• Minimum of 3 years of progressive clinical nursing experience.

Preferred Qualifications:

• Experience with utilization review processes.
• Experience with Medicare Part C appeals.
• Proven experience in clinical appeals.
• Proficiency with computer skills, including Microsoft Outlook, Windows operating systems, and navigating multiple computer systems.
• Excellent time management and organizational skills with the ability to prioritize tasks effectively.
• Exceptional verbal and written communication skills, with the ability to communicate complex information clearly and concisely.

Education: Associate's Degree or Registered Nurse (RN) Diploma required.

Compensation & Benefits

The typical pay range for this role is $61,360.00 - [Insert Salary Range Here]. The actual base salary offer will be determined based on factors such as experience, education, geographic location, and other relevant qualifications. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay.

CVS Health is committed to the well-being of our employees and offers a comprehensive benefits package, including medical, dental, and vision insurance. Eligible employees can participate in our 401(k) retirement savings plan and Employee Stock Purchase Plan. Additional benefits include term life insurance, short-term and long-term disability coverage, well-being programs, education assistance, professional development courses, a CVS store discount, and discounts through partner programs. We also offer Paid Time Off (PTO) and paid holidays consistent with state law and company policies.

Ready for an Easy Start?

This remote position offers a rewarding career with a focus on making a positive impact. If you are a reliable, detail-oriented nurse with a passion for helping others, we encourage you to apply!

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