# Clinical Appeals Nurse

**Company**: CVS Health
**Location**: Work from home, KY, KY
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $54,095.00 - $116,760.00
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/KY---Work-from-home/Appeals-Nurse-Consultant--MUST-live-in-KY_R1034663-1?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/jobs/job_ddb8b068-b85

## Description

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

Responsible for intake, investigation, and resolution of appeals, complaints, and grievances scenarios for all products. You will ensure timely, customer-focused responses to appeals, complaints, and grievances, identifying trends and emerging issues, and recommending solutions.

Key responsibilities:

- Review and resolve clinical documentation, clinical complaints, and appeals

- Interpret data from clinical records, applying clinical criteria and policies in line with regulatory and accreditation requirements

- Coordinate clinical resolution with internal/external clinician support as required

- Gather data from multiple system applications, contacting providers, vendors, or internal departments as needed

- Apply comprehensive knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements

- Condenses complex information into a clear clinical picture, working independently

- Collaborate with members, providers, regulators, and internal/external consultants

- Report findings, respond to rebuttal issues, and make recommendations for improvement

- Identify trends and emerging issues, reporting and giving input on potential solutions

Requirements:

- Unrestricted active nursing license

- 3-5 years of clinical experience, with 3-5 years of Behavioral Health Experience

- Excellent verbal and written communication skills, with excellent customer service skills

- Experience in reading or researching benefit language

Preferred qualifications:

- Managed Care experience

Education:

- RN with current unrestricted state licensure required

Benefits:

- Comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources

Salary range: $54,095.00 - $116,760.00 per year

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## Skills

### Required
- clinical documentation
- clinical complaints
- appeals
- regulatory requirements
- accreditation requirements
- complex delegation arrangements
- coding logic
- contracts
- clinical criteria
- benefit plan structure

### Nice to have
- Managed Care experience

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Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/KY---Work-from-home/Appeals-Nurse-Consultant--MUST-live-in-KY_R1034663-1?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)