[Hiring] Appeals Nurse Consultant @CVS Health

Role Description

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.

Qualifications

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.

Requirements

• 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.

Benefits

• 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.
• Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.