[Remote] Appeals Nurse Consultant at CVS Health

Connecticut, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Active and unrestricted RN licensure in state of residence
3+ Years of clinical experience
Excellent verbal and written communication skills
Strong organizational skills
Associate's Degree in Nursing required
Bachelor's Degree preferred
Appeals Experience (Preferred)
Utilization Review (Preferred)
Medicare Experience (Preferred)
Proficiency with computer skills including Microsoft Outlook, Windows, navigating multiple systems and keyboarding

Responsibilities

Process the medical necessity of Medicare Part C appeals from both members and providers
Request clinical information
Research and extrapolate pertinent clinical information
Apply appropriate Medicare Guidelines
Navigate through multiple computer system applications
Review & prepare appeals submitted by patients or healthcare providers for MD review
Collaborate with internal business partners and external entities to gather and evaluate necessary information
Provide written recommendations or decisions based on available clinical, ensuring adherence to CVS Health and Medicare guidelines
Attend and participate in department meetings
Maintain meticulous attention to detail with accurate documentation
Prepare templates using structured decision-making frameworks extrapolating pertinent clinical information from patient records
Be time efficient and highly organized
Stay on top of a variety of tasks simultaneously
Work independently as well as in a team environment while working remotely

Skills

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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