Position at a Glance: Location: Remote Company: CVS Health Position: Senior Clinical Appeals Consultant Start Date: Immediate openings available Compensation: Competitive salary with bonus potential Join CVS Health: Where Compassion Meets Innovation At CVS Health, our core purpose is to bring our heart to every moment of your health. We are dedicated to delivering enhanced, human-centric healthcare in a rapidly evolving world. Our brand is built on compassion, and this ethos permeates how we approach our work – recognizing that the way we deliver our services is just as vital as the services themselves. Our Heart At Work Behaviors ® embody this commitment, empowering every team member to contribute to a transformative culture and drive innovation for more personal, convenient, and affordable healthcare solutions. This is a full-time, fully remote position offering a flexible work schedule with core hours Monday-Friday from 8:00 AM to 5:00 PM. The role requires rotational weekend and holiday coverage to ensure continuous service delivery. Position Summary As a Senior Clinical Appeals Consultant, you will play a critical role in ensuring the fair and accurate processing of Medicare Part C appeals for both members and healthcare providers. This is a high-volume, impactful role within our dedicated Nurse Appeals team. You will leverage your clinical expertise and strong understanding of Medicare guidelines to review appeal submissions, gather necessary information, analyze clinical documentation, and make informed recommendations. This position demands independence, strong teamwork skills, and the ability to thrive in a fast-paced, dynamic environment. The Medicare Clinical Appeals Team operates 365 days a year, seven days a week, and this role requires scheduled weekend and holiday work. Key Responsibilities Conduct comprehensive reviews of Medicare Part C appeals from members and providers, ensuring thoroughness and accuracy. Expertly interpret and apply complex Medicare guidelines, regulations, and policies to determine medical necessity. Proactively request and analyze additional clinical information from providers, members, and other relevant sources to support the appeals process. Utilize multiple computer systems and navigate complex databases efficiently to gather information and document appeal decisions. Maintain meticulous and accurate documentation of all appeal reviews, findings, and recommendations. Collaborate effectively with internal teams, including medical directors, legal counsel, and other stakeholders, to ensure consistent and compliant appeal outcomes. Identify trends and patterns in appeal submissions to contribute to process improvements and enhance the efficiency of the appeals process. Provide guidance and support to other team members, particularly those new to the appeals process. Maintain up-to-date knowledge of Medicare changes and updates that may impact the appeals process. Contribute to the development and improvement of appeal review tools and resources. Ensure compliance with all applicable privacy and security regulations. Required Qualifications Active and unrestricted Registered Nurse (RN) license in the state of residence. Minimum of 3 years of progressive clinical nursing experience in a relevant setting (e.g., acute care, specialty care, home health). Preferred Qualifications Experience with utilization review processes and Medicare appeals. In-depth knowledge of Medicare Part C regulations and guidelines. Proven ability to effectively navigate and utilize multiple computer systems. Exceptional time management and organizational skills with a demonstrated ability to prioritize tasks in a fast-paced environment. Outstanding verbal and written communication skills, with the ability to clearly and concisely articulate complex medical information. Proficiency in Microsoft Office Suite (Outlook, Word, Excel). Education Associate's Degree or Registered Nurse (RN) Diploma required. Compensation & Benefits The typical pay range for this role is $61,360.00 - $132,600.00 , representing the base hourly rate or full-time annual salary. The actual salary offered will be determined based on factors such as experience, education, geographic location, and other relevant qualifications. This position is eligible for a competitive CVS Health bonus, commission, and short-term incentive programs in addition to the base pay. CVS Health is committed to the well-being of its 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. We also provide a fully-paid term life insurance plan, short-term and long-term disability benefits, and a variety of well-being programs, education assistance, and professional development opportunities. Additional perks include a CVS store discount and discounts through participating partners. Employees enjoy Paid Time Off (PTO) and paid holidays in accordance with company policy and applicable state laws. For detailed information on our benefits, please visit jobs.cvshealth.com/benefits . COVID-19 Vaccination Requirement: CVS Health requires all employees to be fully vaccinated against COVID-19, including any recommended booster shots, unless a reasonable accommodation is approved based on disability, medical condition, religious belief, or other legally recognized reasons. Proof of vaccination is required prior to the start date, or a request for a reasonable accommodation must be submitted within the first 10 days of employment. Please note that in some locations and roles, full vaccination or an approved accommodation may be a condition of employment. Equal Opportunity Employer: CVS Health is an equal opportunity employer committed to diversity, equity, and inclusion. We are dedicated to providing equal access to employment opportunities and will make reasonable accommodations for individuals with disabilities to perform the essential functions of the job. For reasonable accommodation requests, please contact
[email protected]. For assistance with speech or hearing disabilities, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). Ready to make a difference? Apply now and join our team of dedicated healthcare professionals! Apply for this job