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
