Sr. Clinical Strategist - Aetna MPPS - Legislative/Regulatory Guidance - RN

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Senior Clinical Strategist is a key member of Aetna’s Medical Policy and Program Solutions (MPPS) team.  This individual contributor will provide clinical project management support, policy and project monitoring for Medical Policy and Program Solutions (MPPS) initiatives. They will support Legislative and Regulatory guidance, CMS directives, policies and processes. The Senior Clinical Strategist will partner with legal, compliance, and regulatory affairs. They will support policy across product lines. They will participate in the development, implementation, and evaluation of clinical programs, scorable action items (SAIs) and partners with the operational support of the programs and policies.  They will collaborate with Payment Integrity for end-to-end management, including:

• Conduct quality assessment and implementation of legislative updates and directives
• Role will support Provider exceptions, legislative and regulatory requirements, and manage system and reporting tools, including AI.
• Role will support CMS directives, including the Final Rule for impact on Medical Policy Clinical policies and programs
• Provide input for Medical Policy implementation of Utilization Management initiatives, determining ROI and annual review processes
• Lead and support SAI (scorable action items) projects; responsible for strategic ideation of resources and effective solutions for project development.
• Determines medical necessity and appropriateness (may include prospective, concurrent, retrospective review/analysis of program submissions, claims)
• Participate in the development, implementation, and evaluation of new claim edits, workflows and clinical programs 
• Monitor existing clinical programs and processes and ensure any changes and updates are successfully implemented
• Perform root cause analytics from clinical, coding, and claim systems perspectives to identify efficiencies and improvements, and initiate changes in workflows
• Render opinions on emerging clinical and coding trends, utilization and network management, plan coverage, and claims policy to develop medical cost containment solutions that meet business needs
• Coordinates/Communicates with constituents to facilitate program optimization
• Supports member / provider experience and collaborates for improvement on NPS (Net Promotor Score)
• Validate proposed medical cost containment ideas that may be managed as scoreable action items (SAIs)

This is a fully remote position. Eligible candidates may live anywhere in the contiguous United States.

Required Qualifications

• Active and unrestricted Registered Nurse (RN) license in state of residence
• 3+ years Utilization review and/or legislative background
• Demonstrated experience in project management including a foundational understanding of project management principles as applied within a managed care or healthcare delivery setting
• Proven track record in meeting project milestones and negotiating for resources.
• Effective verbal and written communication.
• Ability to work independently as well as collaborate with colleagues from across organization
• Proficiency in Microsoft Office Suite applications including Excel, Word, and Outlook

Preferred Qualifications

• Clinical Claim Review background
• Technical/professional clinical expertise and experience relevant to business area.
• Working knowledge of MPPS programs, including Payment Policies, Precertification and Clinical Claim Review (CCR)
• Medicare and Commercial managed care background
• Understanding of Medicaid Health Plans, Aetna's standard contracts and provider contracting methodologies
• Working knowledge of claim systems preferred
• Understanding of clinical editing concepts (Ex: Program Integrity, Code Edit Third Party Vendors)

Education

Nursing degree and equivalent work experience

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$78,331.00 - $168,714.00

This pay range represents the base hourly rate