Clinical Team Lead
About The Position
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 Summary Own the hands-on execution of root cause investigation and corrective action implementation within a specific line of business and appeal type. You are the subject matter expert closest to the actual appeal cases — researching individual RCAs, documenting findings, executing fixes, and validating that changes are reducing overturn volumes. This role bridges the gap between analytical findings and operational remediation.
Requirements
- 5+ years in healthcare appeals processing, claims adjudication, utilization management, medical policy, or coding — depending on workstream assignment
- For clinical SMEs: clinical credentials or deep working knowledge of UM review criteria, medical necessity determination, CPB/LCD/NCD application, or coding edit rules (E&M, incidental, mutually exclusive)
- Hands-on experience investigating individual appeal cases and tracing denial root causes across systems
- Ability to work across LOBs — understanding differences between Medicare Par, Medicare MNP, and Commercial appeal handling
- Strong documentation skills for RCA write-ups and corrective action tracking
- Must have active and unrestricted RN licensure in state of residence.
Nice To Haves
- Exceptional Communication skills
- Effective time management skills
- Highly organized, ability to multi-task
Responsibilities
- Conduct detailed root cause analysis on assigned L2/L3 addressable opportunities — including individual case review, 5 Whys documentation, and pattern identification
- Research specific RCA issues (e.g., RCA 408 Novologix auth match issues, RCA 542 late contract loading, RCA 566 Medicare drug E/I denials) through case-level deep dives
- Document root causes with supporting case examples, impacted volumes, and LOB breakdowns (Medicare Par, Medicare MNP, Commercial)
- Support Root cause of clinical appeals for Commercial UM/MPO/Coding
- Execute agreed corrective actions within your function — working directly with operational teams, system owners, and upstream partners
- Coordinate with relevant partners: Network/Provider Contracting for rate issues, MPPS for payment policy changes, UM COE for clinical workflow modifications, EviCore for third-party review process changes
- Track implementation milestones and provide regular updates on status, roadblocks, risks, and issues
- Validate that addressable volumes are impacted by implemented changes, with support from Analytical Support
- Compare pre- and post-implementation appeal and overturn trends to confirm corrective action effectiveness
- Flag cases where expected impact is not materializing and investigate contributing factors
- Participate in twice-weekly Workstream Touchpoints, providing case-level updates and surfacing emerging patterns
- Agree to corrective action timelines and deliverables with the Workstream Lead
- Contribute domain expertise to the identification of new addressable opportunities beyond the current 14 L2 drivers
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
