Utilization Management Appeals Nurse Consultant

The Appeals Nurse Consultant resolves clinical complaints and appeals by reviewing medical records and applying clinical guidelines within the Utilization Management group at American Health Holding (a division of Aetna/CVS Health). Schedule is Monday–Friday, 9:30am–5:30pm EST, with possible weekend coverage based on business needs.

Day-to-day work includes administering review and resolution of clinical appeals, interpreting clinical record data, applying MCG/InterQual and internal medical policy, ensuring compliance with state regulatory and accreditation requirements, and coordinating clinical resolutions with internal and external partners.

This is a 100% remote role (U.S. only). Candidates must have a dedicated, interruption-free workspace and separate dependent-care arrangements during shift hours.

Required: active unrestricted RN license in state of residence; 3+ years UM/UR experience; 1+ year working knowledge of MCG, InterQual, or equivalent clinical guidelines and applicable state regulations; 3+ years clinical nursing experience with 1–3 years managed care in UR or medical claims review; 1+ year ICD-9, CPT, and HCPC coding experience. ADN required; BSN preferred. Compact/multistate licensure and prior appeals experience preferred.

Pay range: $60,522–$129,615 plus bonus eligibility.