Appeals Nurse Consultant

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 SummarySchedule: Monday- Friday, standard business hours (8am-5pm in designated time zone) with occasional weekends and holidays on a rotation schedule.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, navigating 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

• Must have active and unrestricted RN licensure in state of residence
• Excellent verbal and written communication skills.
• Strong organizational skills
• 3+ Years Clinical Experience

Preferred Qualifications

• Appeals Experience
• Utilization Review
• Medicare Experience

Education

• Associates Degree in Nursing required
• Bachelor's Degree in Nursing preferred

Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$66,575.00 - $142,576.00This 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 peopleWe 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/benefitsWe anticipate the application window for this opening will close on: 07/24/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Client-provided location(s): Hartford, CT

Job ID: CVS-R0642130

Employment Type: OTHER

Posted: 2025-07-24T12:30:29