Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time telework position.

Hours for this position are Monday-Friday 8a-4:30p

Position Summary
Review grievance and appeal cases for medical necessity and create summaries for medical director reviews

A Brief Overview
Administers review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers. Coordinates clinical resolutions with internal and external support areas.

What you will do
Acts as a top-level specialist to implement best in class policies, plans, and procedures in support of the Appeals area objectives.
Executes review of all clinical and benefit documentation for complaint and appeal requests.
Develops strategy for review requirements to assure case reviews are overseen by practitioners with relevant clinical expertise.
Applies advanced knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements to support appeals review.
Ensures appeal process compliance with regulatory and accreditation standards.
Counsels with members, representatives, providers, regulators, and participants on the appeals process in compliance with state regulation and benefit plan designs.
Coaches and trains junior colleagues in techniques, processes, and responsibilities.

For this role you will need Minimum Requirements
Basic awareness of problem solving and decision making skills

Required Qualifications
Active and unrestricted RN licensure in state of residence
1+ year of UM or Appeals review experience

Preferred Qualifications

Previous health insurance experience

Case Management experience

Education
Associate’s Degree required

Pay Range

The typical pay range for this role is:

$29.10 – $129,600.00

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits