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.

Required Qualifications

• A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all noncompact states.
• 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience.
• 1+ year of experience demonstrating knowledge of ICD-9, CPT coding and HCPC.
• 1+ years of experience demonstrating knowledge of clinical and medical policy, MCG, InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.

Preferred Qualifications

• 5+ years Clinical Nursing experience, including hospital acute care/medical experience.
• 1+ years of Appeals experience in Utilization Management
• 3+ years utilization review experience.

Education

Associate degree RN required, BSN preferred or Bachelor's degree in Nursing preferred.

Pay Range

The typical pay range for this role is:

$54,095.60 - $116,760.80

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 Benefits | CVS Health

We anticipate the application window for this opening will close on: 11/01/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.