Utilization Management Appeals Nurse Consultant (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 Information

Schedule: Monday-Friday 9:30am-5:30pm EST Hours (Shift times may vary with possible weekends based on business needs)

Location: 100% Remote (U.S. only)About Us

American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team.Position Summary

The Appeals Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical records and applying clinical guidelines for Utilization Management group. This RN must be licensed in the state that they reside, with strong experience in utilization review, coding, and managed care.Key Responsibilities

• 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.

• 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.

• 3+ years Utilization Management or Utilization Review experience.
• 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(s) of experience demonstrating knowledge of ICD-9, CPT coding and HCPC.
• 1+ year(s) of experience demonstrating knowledge of clinical and medical policy, Milliman Care Guidelines (MCG), InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges.

• 1+ year(s) of Appeals experience in Utilization Management.

• Associate's degree in nursing (RN) required, BSN preferred.

• 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.