Grievance and Appeal RN (Remote)

Bring your heart to reputed company. Every one of us at reputed company 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 reputed company deliver. Our Heart At Work Behaviors? support this purpose. We want everyone who works at reputed company to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to reputed company 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 reputed company 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 reputed company delegation arrangements, coding logic, reputed company, 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 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 reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company 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. reputed company also offers numerous well-being programs, education assistance, free development courses, a reputed company 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 We anticipate the application window for this opening will reputed company on: 05/31/2024 Apply Job! For more such jobs please click here!