Appeals Nurse Consultant

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

📋 Description

• Request and investigate submitted provider clinical information to assist with case review and determination processes.

• Analyze documentation to pinpoint relevant clinical details and adhere to CMS guidelines, regulatory requirements, and applicable supplemental policies.

• Create thorough nurse summaries for evaluation by the medical director or finalize appeal decisions following pre-approved workflows.

• Navigate and manage various computer systems and applications to ensure timely, accurate, and compliant case processing.

• Operate independently while fostering teamwork and collaboration in a virtual setting.

• Engage in prolonged computer usage, standardized template application, data entry, and typing activities.

• Assess denied outpatient procedures, imaging, and medications for medical necessity using CMS and Aetna criteria.

• Examine denied inpatient stays by scrutinizing medical records and appeals criteria.

• Review down-coded claims and ascertain whether the assigned DRGs are validated by medical records, coding, and clinical guidelines.

• Analyze clinical documentation and coding for denied claims and offer evidence-based recommendations.

• Conduct clinical reviews for claim denials, including CCR and SIU cases, to decide if cases should be overturned or escalated for medical director review.

• Collaborate with various departments, Medical Directors, Project Management, Medicare Appeals Analysts, and Data Science teams.

⛳️ Requirements

• 3-5 years of experience as a Registered Nurse.

• At least 3 years of clinical/hospital nursing experience.

• Registered Nurse - associate’s degree or Diploma RN required.

• Active RN State License Required.

• 1 or more years in Medicare Utilization Management, case review, or prior authorization preferred.

• Experience in Utilization Management, Managed Care, or Appeals preferred.

• Coding experience preferred.

• Pre-Authorization experience preferred.

🏝️ 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 supporting physical, emotional, and financial well-being, based on eligibility.