Appeals Nurse Consultant

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.

Summary Administers review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers. Coordinates clinical resolutions with internal and external support areas.

Acts as a top-level specialist to implement best in class policies, plans, and procedures in support of the Appeals area objectives. Executes review of all clinical and benefit documentation for complaint and appeal requests (for integrated Medicare/Medicaid plans) Develops strategy for review requirements to assure case reviews are overseen by practitioners with relevant clinical expertise. Applies advanced knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements to support appeals review. Ensures appeal process compliance with regulatory and accreditation standards. Counsels with members, representatives, providers, regulators, and participants on the appeals process in compliance with state regulation and benefit plan designs. Coaches and trains junior colleagues in techniques, processes, and responsibilities.

Candidate must have active and unrestricted Registered Nurse (RN) License in their state of residence Candidate must be willing to obtain a Compact Registered Nurse (RN) License within 3 months of hire 3+ years of Medicare/Medicaid Appeal Processing/Review Experience Preferred Qualifications Utilization management or appeals experience Education Associate's Degree in Nursing OR Nursing Diploma (REQUIRED) Bachelor's Degree (PREFERRED) License Active and unrestricted Registered Nurse (RN) License in their state of residence Work from Home Requirements You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted. A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours. Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live. The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time). If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements. Technical and Logistical Requirements Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency. Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings. Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace). Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links. Troubleshooting & Support: Ability to resolve common