Appeals Nurse Consultant - Fully Remote

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary Normal Working Hours: Monday through Friday 8:00am – 5:00pm EST with some weekends depending on business needs American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members. 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. Required Qualifications • A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all noncompact states. • 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience. • 1+ year of experience demonstrating knowledge of ICD-9, CPT coding and HCPC. • 1+ years of experience demonstrating knowledge of clinical and medical policy, MCG, InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines. Preferred Qualifications • 5+ years Clinical Nursing experience, including hospital acute care/medical experience. • 1+ years of Appeals experience in Utilization Management • 3+ years utilization review experience. Education • Associate degree RN required • BSN preferred or Bachelor's degree in Nursing preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $54,095.00 - $116,760.00 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. 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 11/02/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job