Appeal Nurse Associate - MUST reside in Kentucky

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. Kentucky residency is required. Hours for this role are Monday-Friday 8:00a-5:00p EST.

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Responsible for the review and resolution of clinical complaints/grievances and appeals. 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. Requires LPN/LVN with unrestricted active license. Assists with reviewing clinical complaint/grievance and appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation. Assists with data gathering that requires navigation through multiple system applications. Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the clinical complaints/grievances and appeals determinations. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination. Seeks guidance from other healthcare professionals in the coordination and administration of the appeal and grievance process.