Medicare PAR Provider Appeals Nurse Consultant

We're building a world of health around every individual , shaping a more connected, convenient, and compassionate health experience.

At CVS Health, you'll be surrounded by colleagues who care deeply, innovate with purpose, hold themselves accountable, and prioritize safety and quality in everything they do.

Position Overview: This is a full-time remote position working from home anywhere in the US, supporting UM Inpatient, UM outpatient, MPO, Coding, or DRG appeal.

Primary Responsibilities:

• Request and research submitted provider clinical information to support case review and determination processes.
• Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies.
• Based on clinical review findings, prepare a comprehensive nurse summary for medical director evaluation or finalize appeal determinations in accordance with pre-approved workflows.
• Navigate and manage multiple computer systems and applications to ensure timely, accurate, and compliant processing of cases.
• Work independently with a high degree of self-motivation while contributing to teamwork and collaboration in a virtual environment.
• Perform duties in a fast-paced, sedentary role that requires extended computer use, utilization of standardized templates, and regular data entry and typing tasks.
• Demonstrates clinical proficiency and ability to consistently apply clinical and regulatory standards in decision-making.

Clinical Appeals Team:

• UM Outpatient: Review denied procedures, imaging, and medications that are on the National Precertification List (NPL) or the Evicore precertification List (ECR) and require prior authorization.
• UM Inpatient: Review denied inpatient stays, including hospital, hospital readmissions, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays.
• DRG: Review and evaluate down-coded claims to determine if the assigned Diagnosis Related Group (DRG) is supported by using medical records to support the claim submission.
• Coding: Review clinical documentation and coding to evaluate the appropriateness of denied claims, ensuring compliance with regulatory guidelines and organizational policies.
• MPO: Conduct clinical reviews for claim denials, including CCR and SIU cases, determining whether cases should be overturned or prepared for MD review.

Required Qualifications:

• 3-5 years of experience as a Registered Nurse
• Minimum 3+ years of clinical/hospital nursing experience

Preferred Qualifications:

• 1+ years in Medicare Utilization Management, case review, or prior authorization
• Utilization Management, Managed Care, or Appeals experience preferred
• Coding experience preferred
• Pre-Authorization experience preferred

Education and Licensure Requirements:

• Registered Nurse - associate's degree or Diploma RN required, BSN preferred
• Active RN State License Required

Anticipated Weekly Hours: 40

Time Type: Full-time

Pay Range $66,575.00 - $142,576.00

Benefits This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.