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CVS HealthPosted 10/19/2026full-timeRemote • Kentucky • United StatesMid-LevelSenior💰 $54,095 - $116,760 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation review, appeals processing, and regulatory compliance, with a strong focus on behavioral health and effective communication. Proven ability to coordinate resolutions and summarize complex clinical information clearly.
Highest-signal resume keywords
Current Unrestricted RN Licensure3–5 Years Clinical Experience3–5 Years Behavioral Health ExperienceKnowledge of Regulatory RequirementsManaged Care Experience
About the role
Key responsibilities & impact- Intake, investigate, and resolve appeals, complaints, and grievances across products
- Review and resolve clinical documentation, clinical complaints, and appeals
- Review clinical records, interpret data, and apply clinical criteria and policies in line with regulatory and accreditation requirements
- Coordinate clinical resolutions with internal and external clinician support
- Gather data using multiple system applications
- Contact providers, vendors, and internal Aetna departments for additional information
- Apply review requirements to ensure cases are reviewed by practitioners with appropriate clinical expertise
- Process appeals in accordance with regulatory and accreditation standards
- Condense complex information into clear and precise clinical summaries
- Coordinate appeals with members, authorized representatives, providers, regulators, consultants, and other participants
- Report findings to team leaders and supervisors, respond to rebuttal issues, and recommend improvements
- Identify and report trends and emerging issues and provide input on potential solutions
Requirements
What you’ll need- Must live in KY
- Current unrestricted state RN licensure required
- 3–5 years of clinical experience required
- 3–5 years of Behavioral Health Experience required
- Experience in reading or researching benefit language
- Excellent verbal and written communication skills
- Excellent customer service skills
- Knowledge of complex delegation arrangements, coding logic, member and provider contracts, clinical criteria, benefit plan structure, and regulatory requirements
- Managed Care experience preferred
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 eligibility
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewAppeals ProcessingData InterpretationClinical Criteria ApplicationBenefit Language ResearchComplex Information SummarizationTrend IdentificationRegulatory Compliance
Soft Skills
Excellent Verbal CommunicationExcellent Written CommunicationCustomer Service Skills
Tools & Technologies
Multiple System Applications
Certifications & Qualifications
Current Unrestricted RN Licensure
Industry Keywords
Managed CareBehavioral HealthClinical ComplaintsGrievancesDelegation ArrangementsCoding LogicMember ContractsProvider Contracts