Appeals Nurse Consultant

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

📋 Description

• Intake, investigate, and address appeals, complaints, and grievances across various products.

• Evaluate and resolve clinical documentation, clinical complaints, and appeals.

• Analyze clinical records, interpret data, and apply clinical criteria and policies in accordance with regulatory and accreditation standards.

• Facilitate clinical resolutions by coordinating with internal and external clinician support.

• Collect data utilizing multiple system applications.

• Reach out to providers, vendors, and internal Aetna departments for further information.

• Implement review requirements to ensure cases are assessed by practitioners possessing the appropriate clinical expertise.

• Process appeals in compliance with regulatory and accreditation guidelines.

• Summarize complex information into clear and concise clinical overviews.

• Coordinate appeals involving members, authorized representatives, providers, regulators, consultants, and other stakeholders.

• Report findings to team leaders and supervisors, address rebuttal issues, and suggest improvements.

• Identify and report trends and emerging issues, providing input on possible solutions.

⛳️ Requirements

• Must reside in KY.

• Current unrestricted state RN licensure is required.

• 3–5 years of clinical experience is necessary.

• 3–5 years of experience in Behavioral Health is required.

• Familiarity with reading or researching benefit language is essential.

• Exceptional verbal and written communication abilities are needed.

• Outstanding customer service skills are a must.

• Knowledge of complex delegation arrangements, coding logic, member and provider contracts, clinical criteria, benefit plan structure, and regulatory requirements is required.

• Managed Care experience is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.