We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Overview: • This is a full-time remote position working from home anywhere in the US. • This position may support UM Inpatient, UM outpatient, MPO, Coding, or DRG appeal • Hours for this position are Monday–Friday, 8am–5pm in the time zone of residence. • The Medicare PAR Provider Appeals Nurse Consultant manages PAR Provider Post Service payment disputes and appeals. The team is comprised of administrative coordinators and clinical nurse consultants/associates that provide timely review of PAR provider disputes and appeals. We are split into 5 focus areas, MPO (Medical Policy Operations), Coding, DRG Assignment, UM (Utilization Management) Inpatient, and UM (Utilization Management) Outpatient types of reviews. • We are known for collaborating with other departments within our organization along with Medical Directors, Project Management, Medicare Appeals Analyst team and the Data Science team. Primary Responsibilities: • Request and research submitted provider clinical information to support case review and determination processes. • Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies. • Based on clinical review findings, prepare a comprehensive nurse summary for medical director evaluation or finalize appeal determinations in accordance with pre‑approved workflows. • Navigate and manage multiple computer systems and applications to ensure timely, accurate, and compliant processing of cases. • Work independently with a high degree of self‑motivation while contributing to teamwork and collaboration in a virtual environment. • Perform duties in a fast‑paced, sedentary role that requires extended computer use, utilization of standardized templates, and regular data entry and typing tasks. • Demonstrates clinical proficiency and ability to consistently apply clinical and regulatory standards in decision-making. Clinical Appeals Team: • UM Outpatient: Um Outpatient Nurses review denied procedures, imaging, and medications that are on the National Precertification List (NPL) or the Evicore precertification List (ECR) and require prior authorization. These appeals are reviewed for medical necessity based on tiered criteria provided by CMS and Aetna. • UM Inpatient: UM Inpatient Nurses review denied inpatient stays that includes, hospital, hospital readmissions, behavioral health, skilled nursing, acute rehabilitation, and long term acute care stays after the services were rendered. This is done by analyzing medical records and appeals criteria. • DRG: DRG Appeals Nurse reviews and evaluates down coded claims to determine if the assigned Diagnosis Related Group (DRG) is supported by using medical records to support the claim submission. This is done by analyzing medical records, applying coding and clinical guidelines, and completing case preps for Medical Director review. DRG reviewers ensure the accuracy and completeness of the claim with payer requirements. • Coding: Coding Appeals Nurse reviews clinical documentation and coding to evaluate the appropriateness of denied claims, ensuring compliance with regulatory guidelines and organizational policies. They collaborate with interdisciplinary teams to support successful appeals by providing clinical expertise and clear, evidence-based recommendations. • MPO: MPO Appeals Nurses conduct clinical reviews for claim denials, including CCR and SIU cases, determining whether cases should be overturned or prepared for MD review. Their focus is ensuring accurate, evidence‑based appeal outcomes by evaluating medical necessity, documentation, and compliance.
