About this Appeals Nurse Consultant - Remote role at CVS Health
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Overview:
- This is a full-time remote position working from home anywhere in the US.
- This position may support UM Inpatient, UM outpatient, MPO, Coding, or DRG appeal
- Hours for this position are Monday–Friday, 8am–5pm in the time zone of residence.
- The Medicare PAR Provider Appeals Nurse Consultant manages PAR Provider Post Service payment disputes and appeals. The team is comprised of administrative coordinators and clinical nurse consultants/associates that provide timely review of PAR provider disputes and appeals. We are split into 5 focus areas, MPO (Medical Policy Operations), Coding, DRG Assignment, UM (Utilization Management) Inpatient, and UM (Utilization Management) Outpatient types of reviews.
- We are known for collaborating with other departments within our organization along with Medical Directors, Project Management, Medicare Appeals Analyst team and the Data Science team.
Primary Responsibilities:
- 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.
- Based on clinical review findings, prepare a comprehensive nurse summary for medical director evaluation or finalize appeal determinations in accordance with pre‑approved workflows.
- Navigate and manage multiple computer systems and applications to ensure timely, accurate, and compliant processing of cases.
- Work independently with a high degree of self‑motivation while contributing to teamwork and collaboration in a virtual environment.
- Perform duties in a fast‑paced, sedentary role that requires extended computer use, utilization of standardized templates, and regular data entry and typing tasks.
- Demonstrates clinical proficiency and ability to consistently apply clinical and regulatory standards in decision-making.
Clinical Appeals Team:
- UM Outpatient: Um Outpatient Nurses review denied procedures, imaging, and medications that are on the National Precertification List (NPL) or the Evicore precertification List (ECR) and require prior authorization. These appeals are reviewed for medical necessity based on tiered criteria provided by CMS and Aetna.
- UM Inpatient: UM Inpatient Nurses review denied inpatient stays that includes, hospital, hospital readmissions, behavioral health, skilled nursing, acute rehabilitation, and long term acute care stays after the services were rendered. This is done by analyzing medical records and appeals criteria.
- DRG: DRG Appeals Nurse reviews and evaluates down coded claims to determine if the assigned Diagnosis Related Group (DRG) is supported by using medical records to support the claim submission. This is done by analyzing medical records, applying coding and clinical guidelines, and completing case preps for Medical Director review. DRG reviewers ensure the accuracy and completeness of the claim with payer requirements.
- Coding: Coding Appeals Nurse reviews clinical documentation and coding to evaluate the appropriateness of denied claims, ensuring compliance with regulatory guidelines and organizational policies. They collaborate with interdisciplinary teams to support successful appeals by providing clinical expertise and clear, evidence-based recommendations.
- MPO: MPO Appeals Nurses conduct clinical reviews for claim denials, including CCR and SIU cases, determining whether cases should be overturned or prepared for MD review. Their focus is ensuring accurate, evidence‑based appeal outcomes by evaluating medical necessity, documentation, and compliance.
Required Qualifications:
- 3-5 years of experience as a Registered Nurse
- Minimum 3+ years of clinical/hospital nursing experience
Preferred Qualifications:
- 1+ years in Medicare Utilization Management, case review, or prior authorization.
- Utilization Management, Managed Care, or Appeals experience preferred
- Coding experience preferred
- Pre-Authorization experience preferred
Education and Licensure Requirements:
- Registered Nurse - associate’s degree or Diploma RN required, BSN preferred
- Active RN State License Required
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00This 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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
