Appeals Nurse Consultant

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. 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. 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. Benefits Medical, dental, and vision coverage Paid time off Retirement savings options Wellness programs Other resources, based on eligibility Job Data by YubHub .