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 information review, applying CMS guidelines, and conducting comprehensive case evaluations. Proficient in navigating multiple systems for accurate case processing and collaborating effectively in a virtual environment.

Highest-signal resume keywords

Registered Nurse LicenseClinical Documentation ReviewMedicare Utilization ManagementCoding ExperiencePre-Authorization Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Information ReviewCase ReviewData EntryMedical Necessity EvaluationEvidence-Based RecommendationsUtilization ManagementAppeals ProcessingDRG Assignment EvaluationStandardized Template UtilizationTyping Skills

Soft Skills

Team CollaborationIndependent WorkCommunication Skills

Tools & Technologies

Computer SystemsApplications for Case Processing

Certifications & Qualifications

Active RN State LicenseAssociate's Degree or Diploma RN

Industry Keywords

CMS GuidelinesRegulatory RequirementsManaged CareOutpatient ProceduresInpatient StaysMedical Director ReviewClinical ReviewsAetna CriteriaAppeals CriteriaCCR and SIU Cases

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 applicable supplemental policies
Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations in accordance with pre-approved workflows
Navigate and manage multiple computer systems and applications for timely, accurate, and compliant case processing
Work independently while contributing to teamwork and collaboration in a virtual environment
Perform extended computer use, standardized template utilization, data entry, and typing tasks
Review denied outpatient procedures, imaging, and medications for medical necessity based on CMS and Aetna criteria
Review denied inpatient stays by analyzing medical records and appeals criteria
Evaluate down-coded claims and determine whether assigned DRGs are supported by medical records, coding, and clinical guidelines
Review clinical documentation and coding for denied claims and provide evidence-based recommendations
Conduct clinical reviews for claim denials, including CCR and SIU cases, determining whether cases should be overturned or prepared for medical director review
Collaborate with departments, Medical Directors, Project Management, Medicare Appeals Analysts, and Data Science teams

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

Benefits

Comp & perks

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