The Appeals Nurse Consultant position is responsible for processing the medical necessity of Medicare Part C appeals from both members and providers. This role is considered a production role and remains as part of the Nurse Appeal Consultant job code. Primary duties may include, but are not limited to: requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare… Guidelines, navigate through multiple computer system applications in a fast paced department. Must work independently as well as in a team environment while working remotely. The Medicare Clinical Appeals Team C Member/Non-Par Team operates 7 days per week, 365 days per year. This position requires some weekends and holidays on a scheduled rotation.
Must be comfortable in a fast-paced environment
Ability to meet deadlines in a deadline intensive environment
High level of adaptability and willingness to embrace change in a fast-paced, demanding environment
Demonstrates a solid understanding of all workflows, policies, and procedures
Must have ability to use hands for repetitive typing, input data, copy, speak clearly, view computer monitors
Responsible for reviewing & preparing appeals submitted by patients or healthcare providers for MD review
Collaborate with internal business partners and external entities to gather and evaluate necessary information
Provide written recommendations or decisions based on available clinical, ensuring adherence to CVS Health and Medicare guidelines.
Attend and participate in department meetings.
Meticulous attention to detail with accurate documentation
Prepare templates using structured decision-making frameworks extrapolating pertinent clinical information from patient records
Proficiency with computer skills including Microsoft Outlook, Windows, navigating multiple systems and keyboarding
Time efficient and highly organized
Exceptional verbal and written communication skills
Highly attentive to detail while taking initiative staying on top of a variety of tasks simultaneously
Required Qualifications
Active and unrestricted RN licensure in state of residence
3+ years of clinical experience
Preferred Qualifications
Utilization Review experience
Medicare experience
Appeals experience
Education
Associate’s Degree or RN diploma required
Pay Range
The typical pay range for this role is:
$61,360.00 $132,600.00
This 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
