Appeals Nurse Consultant

CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Key Responsibilities

• Responsible for the review and resolution of clinical appeals.
• Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
• Independently coordinates the clinical resolution with internal/external clinician support as required.
• This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.
• This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
• Occasional weekend and holiday on-call coverage may be required.

Remote Work Expectations

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required Qualifications

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.

Preferred Qualifications

• Appeals, Managed Care, or Utilization Review experience.
• Proficiency with computer skills including navigating multiple systems.
• Exceptional communication skills.
• Time efficient, highly organized, and ability to multitask.

Education

• Associate's Degree minimum.

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility