Appeals Nurse Consultant

About the role

CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Key responsibilities

• Responsible for the review and resolution of clinical appeals.
• Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
• Independently coordinates the clinical resolution with internal/external clinician support as required.
• This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.

Remote work expectations

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required qualifications

• Must have active and unrestricted RN licensure in state of residence.
• 3+ years clinical experience.

Preferred qualifications

• Appeals, Managed Care, or Utilization Review experience.
• Proficiency with computer skills including navigating multiple systems.
• Exceptional communication skills.
• Time efficient, highly organized, and ability to multitask.

Education

• Associate's Degree minimum.

Schedule

• This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
• Occasional weekend and holiday on-call coverage may be required.
• Anticipated weekly hours: 40

Pay

• The typical pay range for this role is $66,575.00 – $142,576.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.
• This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.