Experienced Appeals Nurse Associate - Remote Opportunity for Kentucky Residents

Transforming Healthcare with CVS Health

At CVS Health, we're driven by a singular purpose: to bring our heart to every moment of your health. As a leading healthcare organization, we're committed to delivering enhanced human-centric health care that's more personal, convenient, and affordable. Our Heart At Work Behaviors guide our commitment to transforming our culture and accelerating our ability to innovate and deliver solutions that make a meaningful difference in the lives of our members.

About the Role

We're seeking an experienced Appeals Nurse Associate to join our team on a full-time remote basis. As an Appeals Nurse Associate, you'll play a critical role in facilitating the delivery of appropriate benefits and healthcare information, while promoting wellness activities and supporting health strategies that drive overall member wellness.

Key Responsibilities

• Review and resolve clinical complaints/grievances and appeals, applying clinical criteria and policies in line with regulatory and accreditation requirements.
• Independently coordinate clinical resolution with internal/external clinician support as required.
• Assist with reviewing clinical complaint/grievance and appeal requests, considering all previous information and additional records/data presented.
• Navigate multiple system applications to gather data and contact providers, vendors, or internal departments to obtain additional information.
• Accurately apply review requirements to ensure cases are reviewed by practitioners with clinical expertise.
• Demonstrate comprehensive knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility.
• Proactively apply regulatory and accreditation standards to ensure timely processing of appeals and ERO requests.

Essential Qualifications

To succeed in this role, you'll need:

• 2+ years of clinical experience.
• Active and unrestricted LPN/LVN licensure.
• Residency in the state of Kentucky.

Preferred Qualifications

• Managed Care experience.
• High School diploma or equivalent.
• Current, unrestricted LPN/LVN licensure.

Skills and Competencies

We're looking for individuals with:

• Strong clinical knowledge and analytical skills.
• Excellent communication and coordination skills.
• Ability to navigate complex systems and applications.
• Strong understanding of regulatory and accreditation requirements.
• Proactive and detail-oriented approach to work.

Career Growth Opportunities

At CVS Health, we're committed to helping our colleagues grow and develop their careers. As an Appeals Nurse Associate, you'll have opportunities to:

• Develop your clinical expertise and knowledge of healthcare regulations.
• Enhance your analytical and problem-solving skills.
• Build your communication and coordination skills.
• Take on new challenges and responsibilities.

Work Environment and Culture

As a remote colleague, you'll enjoy the flexibility and autonomy of working from home, while still being part of a collaborative and dynamic team. Our culture is built on our Heart At Work Behaviors, which guide our commitment to delivering exceptional healthcare and making a positive impact on our members' lives.

Compensation and Benefits

We offer a competitive salary and a comprehensive benefits package, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan and Employee Stock Purchase Plan.
• Term life insurance and disability benefits.
• Well-being programs and education assistance.
• CVS store discount and discount programs with participating partners.
• Paid Time Off (PTO) and paid holidays.

The typical pay range for this role is $20.34 - $43.77 per hour. The actual base salary offer will depend on a variety of factors, including experience, education, geography, and other relevant factors.

Join Our Team!

If you're a motivated and compassionate healthcare professional looking for a new challenge, we encourage you to apply for this exciting opportunity. As an Appeals Nurse Associate, you'll play a critical role in driving the delivery of high-quality healthcare and making a positive impact on our members' lives. Apply today and join our team of dedicated colleagues who are transforming the healthcare landscape!