Appeals Nurse Consultant

This is a fully remote position, open to applicants in West Virginia.

📋 Description

• Assess and resolve clinical appeals.

• Evaluate documentation and analyze data from clinical records.

• Implement relevant clinical criteria and policies in accordance with regulatory and accreditation standards.

• Address concerns from members and providers.

• Independently manage clinical resolutions with both internal and external clinician support as necessary.

• Assist with UM (including expedited), MPO, Coding, or Behavioral Health appeals.

• Work schedule is Monday to Friday, 8:00 AM to 5:00 PM local time.

• Provide occasional weekend and holiday on-call support as required.

⛳️ Requirements

• Active and unrestricted RN license in the state of residence.

• A minimum of 3 years of clinical experience.

• At least an Associate's Degree.

• Experience in Appeals, Managed Care, or Utilization Review.

• Proficient in computer skills and adept at navigating multiple systems.

• Outstanding communication abilities.

• Efficient with time management, highly organized, and capable of multitasking.

• A dedicated workspace that is free from interruptions.

• Dependents must have alternative care arrangements during working hours.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.