We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.
Key Responsibilities
Responsible for the review and resolution of clinical appeals.
Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
Independently coordinates the clinical resolution with internal/external clinician support as required.
This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.
This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
Occasional weekend and holiday on-call coverage may be required.
Remote Work Expectations
This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.
Required Qualifications
Must have active and unrestricted RN licensure in state of residence.
3+ years clinical experience.
Preferred Qualifications
Appeals, Managed Care, or Utilization Review experience.
Proficiency with computer skills including navigating multiple systems.
Exceptional communication skills.
Time efficient, highly organized, and ability to multitask.
Education
Associate's Degree minimum.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job details are sourced from the employer's original posting.
Open job postingAbout the company
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come. Excellent benefits package, including 401k, tuition, licensure and certification reimbursement. We promote healthy & wellness lifestyles and offer specialty programs here at Aetna. We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence. Together we will empower people to live healthier lives. Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities. We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.