Skip to main content

A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Appeals Nurse Analyst

Primary Location: Richmond, VA
Additional Locations: VA-Richmond
Responsible for the review and resolution of clinical complaints 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.

Onsite site in Richmond, VA.
Standard business hours and rotating weekends approximately 1 weekend a month on call.
No nights and no holidays.

Fundamental Components:
Assists with reviewing complaint / appeal requests of all clinical determinations/clinical policies. Considers all 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 Aetna departments to obtain additional information.* Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the applicable appeal issue.* Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the appeals determinations.* Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within 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 healthcare professionals in the coordination and administration of the appeals process*
Demonstrates Best in Class letter writing skills. All letters are drafted individually based on current findings, regulations and legislations.

Background Experience:
Managed Care experience preferred
1 year minimum of clinical nursing experience preferred

Graduate of a Registered Nurse Program preferably or a License Practical Nurse Program (LPN).
Must pass the Virginia State Nursing Boards within six months of receiving Graduate Nurse Status.

Associate's Degree in Nursing or equivalent is required.
A minimum of 636 clinical training hours from an Accredited Associate/Bachelors Degree Nursing Program

Additional Job Information:
Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment

Desired Skills:
General Business - Communicating for Impact, General Business - Consulting for Solutions, Leadership - Collaborating for Results, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs

Functional Skills:
Administration / Operation - File Maintenance, Clinical / Medical - Clinical claim review & coding, Medical Management - Medical Management - Clinical claim review, Medical Management - Medical Management - Clinical coverage and policies, Medical Management - Medical Management - Complaints, Grievance & Appeals

Technology Experience:
Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Nursing - Registered Nurse, Nursing - Registered Nurse (RN)

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests

Click To Review Our Benefits (PDF)


Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.