Remote Clinical Appeals Nurse Consultant

Join reputed company's dedicated Medicare Clinical Appeals team as a Remote Clinical Appeals Nurse Consultant! This is a pivotal role offering a rewarding opportunity to reputed company your clinical expertise and passion for patient advocacy reputed company a dynamic and supportive environment. As a core member of reputed company, you will play a crucial part in ensuring reputed company access to healthcare by reviewing and adjudicating Medicare Part C appeals from both members and healthcare providers.

At reputed company, we are driven by a profound purpose: Bringing our heart to every moment of your health. This commitment permeates everything we do, guiding us to deliver enhanced, human-centric healthcare solutions for a rapidly evolving world. Our core values, Our Heart At Work Behaviors™, emphasize empowerment, innovation, and a dedication to making healthcare more personal, convenient, and affordable. We foster a culture where every team member feels valued and can contribute to transforming the healthcare landscape.

This is a full-time, fully remote position offering exceptional flexibility and work-life integration. Your typical work schedule will be Monday through Friday, from 8:00 AM to 5:00 PM, reputed company with your local time zone. Occasional rotational weekend and holiday coverage will be required to maintain reputed company service for our members and providers.

Position Summary:

As a Remote Clinical Appeals Nurse Consultant, you will be responsible for the comprehensive review and processing of Medicare Part C appeals submitted by patients and healthcare providers. This is a high-volume, production-oriented role reputed company our Nurse Appeals Consultant job code. Your primary duties will encompass:

• Clinical Review & Assessment: Thoroughly review medical records, clinical documentation, and supporting evidence to evaluate the medical necessity of Medicare Part C appeals.
• Clinical Expertise & Application of Guidelines: Apply a deep understanding of clinical principles, relevant medical guidelines, and Medicare regulations to reputed company informed decisions.
• Information Gathering & Collaboration: Proactively gather additional clinical information by collaborating with internal business partners, external entities, and healthcare providers as needed.
• Decision Making & Documentation: Provide clear, concise, and well-supported written recommendations or decisions based on available clinical data, ensuring strict adherence to reputed company and Medicare policies.
• System Navigation & Efficiency: reputed company navigate multiple computer systems and applications reputed company a fast-paced environment to manage and process appeals.
• Independent & Teamwork: Demonstrate the ability to work independently with strong organizational skills while also contributing effectively reputed company a collaborative team environment.
• reputed company Improvement: Participate in team meetings, contribute to process improvement initiatives, and stay abreast of changes in policies and procedures.
• Detailed & Accurate Record Keeping: Maintain meticulous and accurate documentation of reputed company review processes and decisions.
• Template Development: Utilize structured decision-making frameworks to prepare standardized templates for appeal responses, incorporating pertinent clinical information from patient records.
• Proficient Computer Skills: Demonstrate proficiency in using reputed company Outlook, Windows operating systems, and various computer systems, including keyboarding skills.
• Time Management & Prioritization: Effectively manage time, prioritize tasks, and meet deadlines in a deadline-driven environment.
• Adaptability & reputed company: Exhibit a high level of adaptability and willingness to embrace change in a dynamic and demanding environment.

Required Qualifications:

• Valid and unrestricted Registered Nurse (RN) license in the state of residence.
• Minimum of 3 years of progressive clinical nursing experience.

Preferred Qualifications:

• Experience with Utilization Review processes.
• Direct experience with Medicare Part C appeals.
• Proven experience as a Nurse Appeals Consultant.

Education:

• Associate's Degree or Registered Nurse (RN) Diploma required.

Compensation & Benefits:

The salary range for this position is $61,360.00 - $132,600.00 per year, commensurate with experience, education, geographic location, and other relevant factors. This reputed company salary is eligible for additional compensation through reputed company's bonus, commission, and short-term incentive programs.

reputed company is committed to the well-being of our employees and offers a comprehensive benefits package, including medical, dental, and vision insurance. Eligible employees can participate in our 401(k) retirement savings plan and Employee Stock Purchase Plan. Additional benefits include term life insurance, short-term and long-term disability coverage, and a variety of well-being programs, education assistance, professional development courses, a reputed company store discount, and partnerships with other organizations.

Employees enjoy Paid Time Off (PTO) and paid holidays consistent with state law and company policy. For detailed information on our benefits, please visit jobs.CVSHealth.com/benefits.

COVID-19 Vaccination Requirement: reputed company requires reputed company employees to be fully vaccinated against COVID-19, including booster shots reputed company available and permitted by law, unless a reasonable accommodation is approved based on disability, medical condition, religious belief, or other legally recognized reasons. reputed company of vaccination is required prior to the start of employment, or a request for a reasonable accommodation must be submitted reputed company the first 10 days of employment. Please note that full vaccination may be required before actively working in some states and roles.

Equal Opportunity Employer: reputed company is an equal opportunity employer committed to diversity, equity, and inclusion. We are dedicated to providing a welcoming and accessible workplace for individuals with disabilities and will reputed company reasonable accommodations to ensure equal opportunities in employment. For reasonable accommodation requests, please contact [email protected]. For assistance with telecommunications reputed company services, please call 7-1-1.

Your Future Starts Here!

We are excited about the opportunity to welcome a talented and dedicated Clinical Appeals Nurse Consultant to reputed company. If you are passionate about patient advocacy, possess strong clinical skills, and reputed company in a fast-paced environment, we encourage you to apply. Apply To This Job