# Medicare PAR Provider Appeals Nurse Consultant

**Company**: CVS Health
**Location**: CT, CT
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $66,575.00 - $142,576.00
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/CT---Work-from-home/Appeals-Nurse-Consultant---Remote_R1094724?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/job/medicare-par-provider-appeals-nurse-consultant-f4989477-9bb/

## Description

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

This is a full-time remote position working from home in Connecticut, supporting PAR Provider Post Service payment disputes and appeals.

**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.

- 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.

**Clinical Appeals Team:**

- UM Outpatient: Reviews denied procedures, imaging, and medications that require prior authorization.

- UM Inpatient: Reviews denied inpatient stays, including hospital, hospital readmissions, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays.

- DRG: Reviews and evaluates down-coded claims to determine if the assigned Diagnosis Related Group (DRG) is supported.

- Coding: Reviews clinical documentation and coding to evaluate the appropriateness of denied claims.

- MPO: Conducts clinical reviews for claim denials, 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:** Eligible for a comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources.

For more fresh new jobs, check out [yubhub.co](https://yubhub.co/).

## Skills

### Required
- Registered Nurse
- Clinical Experience
- CMS Guidelines

### Nice to have
- Medicare Utilization Management
- Case Review
- Prior Authorization
- Coding
- Pre-Authorization

---

Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/CT---Work-from-home/Appeals-Nurse-Consultant---Remote_R1094724?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)