Appeals Nurse Consultant (Remote)

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Bring your heart to Aetna Health. Every one of us at Aetna Health shares a single, clear purpose: Bringing our heart to every moment of your health. T

his 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 what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at Aetna Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time telework position.

Hours for this role are Monday-Friday 8a-5p in time zone of residence with occasional rotational weekend and holiday coverage.

Position Summary

The Appeals Nurse Consultant position is responsible for processing the medical necessity of Medicare Part C appeals from both members and providers. This role is considered a production role and remains as part of the Nurse Appeal Consultant job code. Primary duties may include, but are not limited to: requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare Guidelines, navigate through multiple computer system applications in a fast paced department. Must work independently as well as in a team environment while working remotely.  The Medicare Clinical Appeals Team C Member/Non-Par Team operates 7 days per week, 365 days per year. This position requires some weekends and holidays on a scheduled rotation.

  • Must be comfortable in a fast-paced environment
  • Ability to meet deadlines in a deadline intensive environment
  • High level of adaptability and willingness to embrace change in a fast-paced, demanding environment
  • Demonstrates a solid understanding of all workflows, policies, and procedures
  • Must have ability to use hands for repetitive typing, input data, copy, speak clearly, view computer monitors
  • Responsible for reviewing & preparing appeals submitted by patients or healthcare providers for MD review
  • Collaborate with internal business partners and external entities to gather and evaluate necessary information
  • Provide written recommendations or decisions based on available clinical, ensuring adherence to Aetna Health and Medicare guidelines.
  • Attend and participate in department meetings.
  • Meticulous attention to detail with accurate documentation
  • Prepare templates using structured decision-making frameworks extrapolating pertinent clinical information from patient records
  • Proficiency with computer skills including Microsoft Outlook, Windows, navigating multiple systems and keyboarding
  • Time efficient and highly organized
  • Exceptional verbal and written communication skills
  • Highly attentive to detail while taking initiative staying on top of a variety of tasks simultaneously

Required Qualifications

  • Active and unrestricted RN licensure in state of residence
  • 3+ years of clinical experience

Preferred Qualifications

  • Utilization Review experience
  • Medicare experience
  • Appeals experience

Education

  • Associate’s Degree or RN diploma required

Pay Range

The typical pay range for this role is:

$61,360.00 – $132,600.00

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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 Aetna 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. Aetna Health also offers numerous well-being programs, education assistance, free development courses, a Aetna 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.

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