Appeals Nurse Consultant

This is a fully remote position, open to applicants in Alabama, +4 more states.

📋 Description

• Manage the review and resolution process for clinical complaints and appeals.

• Analyze clinical-record data and apply clinical criteria and policies to ensure compliance with regulatory and accreditation standards.

• Collaborate with both internal and external support teams to coordinate clinical resolutions.

• Execute policies, plans, and procedures that align with the objectives of the Appeals area.

• Assess clinical and benefit documentation related to complaint and appeal requests for integrated Medicare/Medicaid plans.

• Formulate review strategies to guarantee that cases are handled by practitioners with appropriate clinical expertise.

• Utilize advanced knowledge of delegation arrangements, coding logic, contracts, clinical criteria, benefit structures, and regulatory requirements.

• Ensure adherence to the appeal process in line with regulatory and accreditation standards.

• Provide guidance to members, representatives, providers, regulators, and participants regarding the appeals process.

• Mentor and train junior staff members.

⛳️ Requirements

• Valid and unrestricted Registered Nurse (RN) license in the state of residence.

• Commitment to obtain a Compact Registered Nurse (RN) license within three months of hiring.

• Over three years of experience in processing/reviewing Medicare/Medicaid appeals.

• Associate's Degree in Nursing or Nursing Diploma (mandatory).

• Bachelor's Degree in Nursing or a related field (preferred).

• Direct/hardwired internet connection to a modem/router within seven feet of the computer.

• Minimum internet speed of 25 Mbps for download and 3 Mbps for upload.

• WiFi and satellite internet connections are not acceptable.

• A quiet, secure, and private designated home workspace that complies with CVS Health and HIPAA guidelines.

• Capability to set up and utilize multiple monitors and navigate various applications.

• Proficient in communicating via email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools like Google Workspace.

• Ability to log into secure systems such as VPN and EHR portals.

• Competence in managing strong passwords and identifying suspicious emails or links.

• Capacity to independently resolve common technical issues.

• Willingness to learn new skills as the workplace evolves.

• Must work from within the state and city of current residence.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Company-provided equipment (keyboard, monitor, computer, headset, etc.).

• Remote work arrangement.