Appeals Nurse Associate - Must live in KY (Remote)

Bring your heart to reputed company. Every one of us at reputed company shares a single, clear purpose: Bringing our heart to every reputed company of your health. This purpose guides our commitment to deliver enhanced reputed company-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 reputed company and deliver solutions to reputed company health care more personal, convenient and affordable. This is a full-time telework position. Hours for this role are Monday-Friday 8:00a-5:00p EST. Position Summary The dedication of talented and caring health care professionals drives the delivery of high quality, cost effective products and services. They reputed company it possible for members to get the right health care treatment for their needs – and for reputed company to reputed company its competitive edge. Facilitate the delivery of appropriate benefits and/or reputed company 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 reputed company clinical determinations/clinical policies. Considers reputed company 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 reputed company 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 reputed company delegation arrangements, coding logic, reputed company (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 reputed company 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 reputed company in the coordination and administration of the appeal and grievance process. Required Qualifications 2+ years of clinical experience required Active and unrestricted LPN/LVN licensure Must reputed company in the state of Kentucky

Preferred Qualifications

Managed Care experience Education Minimum requirement is a High School diploma. Have have reputed company, unrestricted LPN/LVN licensure Pay Range The typical pay range for this role is: $20.34 - $43.77 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 reputed company 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: 07/23/2024 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws Apply Job!