Appeals Nurse Consultant

CVS Health

. Request and research submitted provider clinical information to support case review and determination processes .

Posted 11/10/2026full-timeRemote • Connecticut • United StatesMid-LevelSenior💰 $66,575 - $142,576 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Review and Utilization Management, applying CMS guidelines and regulatory requirements to evaluate medical documentation and claims. Proficient in preparing nurse summaries and collaborating across departments to ensure compliance and timely case processing.

Highest-signal resume keywords

Registered Nurse LicenseUtilization Management ExperienceClinical Review ProficiencyCMS Guidelines ApplicationCoding Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewCase ReviewPrior AuthorizationCoding Guidelines ApplicationData EntryEvidence-Based RecommendationsMedical Record EvaluationRegulatory ComplianceClinical ProficiencyMPO Clinical Reviews

Soft Skills

CollaborationIndependent WorkAttention to DetailCommunication

Tools & Technologies

Computer SystemsData Management Applications

Certifications & Qualifications

Active RN State LicenseAssociate's Degree or Diploma RN

Industry Keywords

Medicare AppealsManaged CareUtilization ManagementClinical GuidelinesHealthcare Compliance

About the role

Key responsibilities & impact

Request and research submitted provider clinical information to support case review and determination processes
Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and supplemental policies
Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations using pre-approved workflows
Navigate multiple computer systems and applications to process cases accurately, compliantly, and on time
Collaborate with administrative coordinators, clinical nurse consultants, Medical Directors, Project Management, Medicare Appeals Analysts, Data Science, and other departments
Review UM outpatient appeals involving denied procedures, imaging, and medications requiring prior authorization
Review UM inpatient appeals involving hospital, readmission, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays
Evaluate down-coded claims and DRG assignments using medical records, coding guidelines, and clinical guidelines
Review coding appeals for denied claims and provide evidence-based recommendations
Conduct MPO clinical reviews for claim denials, including CCR and SIU cases
Work independently in a virtual team environment while performing sedentary computer-based duties, data entry, typing, and use of standardized templates

Requirements

What you’ll need

3-5 years of experience as a Registered Nurse
Minimum 3+ years of clinical/hospital nursing experience
Registered Nurse associate’s degree or Diploma RN required
Active RN State License Required
1+ years in Medicare Utilization Management, case review, or prior authorization preferred
Utilization Management, Managed Care, or Appeals experience preferred
Coding experience preferred
Pre-Authorization experience preferred
Ability to apply CMS guidelines, regulatory requirements, and applicable supplemental policies
Clinical proficiency and ability to consistently apply clinical and regulatory standards in decision-making

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
CVS Health bonus, commission or short-term incentive program in addition to base pay