Remote Clinical Appeals Nurse Consultant

Join CVS Health's dedicated Medicare Clinical Appeals team as a Remote Clinical Appeals Nurse Consultant! This is a pivotal role offering a rewarding opportunity to leverage your clinical expertise and passion for patient advocacy within a dynamic and supportive environment. As a core member of our team, you will play a crucial part in ensuring equitable access to healthcare by reviewing and adjudicating Medicare Part C appeals from both members and healthcare providers.

At CVS Health, we are driven by a profound purpose: Bringing our heart to every moment of your health. This commitment permeates everything we do, guiding us to deliver enhanced, human-centric healthcare solutions for a rapidly evolving world. Our core values, Our Heart At Work Behaviors™, emphasize empowerment, innovation, and a dedication to making healthcare more personal, convenient, and affordable. We foster a culture where every team member feels valued and can contribute to transforming the healthcare landscape.

This is a full-time, fully remote position offering exceptional flexibility and work-life integration. Your typical work schedule will be Monday through Friday, from 8:00 AM to 5:00 PM, aligned with your local time zone. Occasional rotational weekend and holiday coverage will be required to maintain continuous service for our members and providers.

Position Summary:

As a Remote Clinical Appeals Nurse Consultant, you will be responsible for the comprehensive review and processing of Medicare Part C appeals submitted by patients and healthcare providers. This is a high-volume, production-oriented role within our Nurse Appeals Consultant job code. Your primary duties will encompass:

• Clinical Review & Assessment: Thoroughly review medical records, clinical documentation, and supporting evidence to evaluate the medical necessity of Medicare Part C appeals.
• Clinical Expertise & Application of Guidelines: Apply a deep understanding of clinical principles, relevant medical guidelines, and Medicare regulations to make informed decisions.
• Information Gathering & Collaboration: Proactively gather additional clinical information by collaborating with internal business partners, external entities, and healthcare providers as needed.
• Decision Making & Documentation: Provide clear, concise, and well-supported written recommendations or decisions based on available clinical data, ensuring strict adherence to CVS Health and Medicare policies.
• System Navigation & Efficiency: Efficiently navigate multiple computer systems and applications within a fast-paced environment to manage and process appeals.
• Independent & Teamwork: Demonstrate the ability to work independently with strong organizational skills while also contributing effectively within a collaborative team environment.
• Continuous Improvement: Participate in team meetings, contribute to process improvement initiatives, and stay abreast of changes in policies and procedures.
• Detailed & Accurate Record Keeping: Maintain meticulous and accurate documentation of all review processes and decisions.
• Template Development: Utilize structured decision-making frameworks to prepare standardized templates for appeal responses, incorporating pertinent clinical information from patient records.
• Proficient Computer Skills: Demonstrate proficiency in using Microsoft Outlook, Windows operating systems, and various computer systems, including keyboarding skills.
• Time Management & Prioritization: Effectively manage time, prioritize tasks, and meet deadlines in a deadline-driven environment.
• Adaptability & Resilience: Exhibit a high level of adaptability and willingness to embrace change in a dynamic and demanding environment.

Required Qualifications:

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

Preferred Qualifications:

• Experience with Utilization Review processes.
• Direct experience with Medicare Part C appeals.
• Proven experience as a Nurse Appeals Consultant.

Education:

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

Compensation & Benefits:

The salary range for this position is $61,360.00 - $132,600.00 per year, commensurate with experience, education, geographic location, and other relevant factors. This base salary is eligible for additional compensation through CVS Health's bonus, commission, and short-term incentive programs.

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, and a variety of well-being programs, education assistance, professional development courses, a CVS store discount, and partnerships with other organizations.

Employees enjoy Paid Time Off (PTO) and paid holidays consistent with state law and company policy. For detailed information on our benefits, please visit jobs.CVSHealth.com/benefits.

COVID-19 Vaccination Requirement: CVS Health requires all employees to be fully vaccinated against COVID-19, including booster shots when available and permitted by law, unless a reasonable accommodation is approved based on disability, medical condition, religious belief, or other legally recognized reasons. Proof of vaccination is required prior to the start of employment, or a request for a reasonable accommodation must be submitted within the first 10 days of employment. Please note that full vaccination may be required before actively working in some states and roles.

Equal Opportunity Employer: CVS Health is an equal opportunity employer committed to diversity, equity, and inclusion. We are dedicated to providing a welcoming and accessible workplace for individuals with disabilities and will make reasonable accommodations to ensure equal opportunities in employment. For reasonable accommodation requests, please contact [email protected]. For assistance with telecommunications relay services, please call 7-1-1.

Your Future Starts Here!

We are excited about the opportunity to welcome a talented and dedicated Clinical Appeals Nurse Consultant to our team. If you are passionate about patient advocacy, possess strong clinical skills, and thrive in a fast-paced environment, we encourage you to apply. Apply To This Job