Utilization Management Appeals Nurse Consultant @ CVS Health
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Job Details
About CVS Health and the Role
At CVS Health, we’re building a world of health around every consumer. As the nation’s leading health solutions company, we serve millions of Americans with a connected, convenient, and compassionate approach. This role is 100% remote for U.S. candidates.
Position Information
The Utilization Management Appeals Nurse Consultant is a key role responsible for reviewing clinical complaints and appeals. The RN will review medical records, apply clinical guidelines, and coordinate resolutions for both members and providers while ensuring compliance with regulatory standards.
Key Responsibilities
- Administer review and resolution of clinical complaints and appeals.
- Interpret data from clinical records using appropriate clinical criteria.
- Ensure compliance with regulatory and accreditation requirements.
- Coordinate resolutions with internal and external support areas.
Remote Work Expectations
This is a 100% remote role requiring a dedicated, interruption-free workspace. Candidates must arrange separate care for dependents during work hours.
Required Qualifications
- 3+ years of experience in Utilization Management or Utilization Review.
- 3+ years of clinical nursing experience with managed care background.
- Experience with ICD-9, CPT coding, and HCPC.
- Knowledge of clinical and medical policies and guidelines, including Milliman Care Guidelines and InterQual.
- Active, unrestricted RN license in the state of residence with multistate/compact privileges.
Preferred Qualifications and Education
Preference for candidates with 1+ year of Appeals experience in Utilization Management and BSN preferred.
Work Schedule and Compensation
Monday–Friday, 9:30 AM - 5:30 PM EST (variable shift times with potential weekends as needed). Anticipated weekly hours: 40. Base salary ranges from $54,095 to $116,760, with eligibility for bonus and incentive programs.
Benefits
Competitive wages and a comprehensive benefits package including affordable medical plans, 401(k) with matching, employee stock purchase, wellness programs, flexible work schedules, and more.
Key skills/competency
- Utilization Management
- Clinical review
- Nursing
- Appeals handling
- ICD-9/CPT coding
- Managed care
- Regulatory compliance
- Remote work
- Communication
- Critical thinking
How to Get Hired at CVS Health
🎯 Tips for Getting Hired
- Customize your resume: Tailor skills and certifications to the role.
- Emphasize remote experience: Highlight work-from-home achievements.
- Research CVS Health: Understand the company culture and values.
- Align with clinical criteria: Focus on utilization and managed care expertise.