Health Services Professional

CVS Health

5d

About The Position

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 primary responsibility of this position is to develop evidence-based medical policies for Aetna, known as Clinical Policy Bulletins (CPBs). The individual will respond to inquiries from Aetna medical directors and clinical staff regarding the medical necessity and proven value of specific items and services eligible for coverage under Aetna's medical benefit plans, emphasizing scientific evidence and supporting rationale. Additionally, the role involves addressing questions about the appropriate interpretation, application, and implementation of the CPBs. The individual will also be responsible for revising and updating the CPBs based on new clinical evidence or other relevant information. Furthermore, the individual will collaborate with internal teams to ensure alignment of Aetna CPBs with organizational goals and processes. This position reports to the Aetna Medical Affairs Executive Director of the Clinical Policy Unit and works directly with other colleagues on the Clinical Policy Unit Team, as well as colleagues across Medical Affairs.

Requirements

• Strong understanding of evidence-based medicine and health technology assessment.
• Deep understanding of methodological principles of clinical study design and statistical methods used in clinical research.
• Facility with PubMed database search engine for accessing published, peer-reviewed medical literature.
• Evaluating the methodological quality of clinical studies
• Conducting literature searches and summarizing the results
• Desktop Tools - Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Excel
• Excellent communication skills: this includes written and verbal skills.
• Superior writing skills that require moderate to minimal editing, and proficiency in technical writing.
• Excellent time management and multi-tasking skills.
• Conduct rapid reviews using PubMed and other relevant clinical evidence resources to identify evidence relevant to the safety and effectiveness of a clinical intervention, identify the highest quality evidence, summarize the results of each of those studies, and reach conclusions about the overall quality of evidence in support of the intervention.
• Candidate is required to have regular and predictable attendance.

Nice To Haves

• Prior relevant work experience related to evidence-based clinical policy development.
• Broad knowledge of clinical medicine, including drugs, biologics, devices, surgical procedures, tests, and therapies.
• Basic understanding of commercial health insurance and Medicare and Medicaid programs.
• Basic understanding of the regulatory environment for medical technologies, including the FDA approval process and Medicare coverage determinations
• Basic understanding of the system of standardized codes used in the billing and tracking of healthcare services to report a patient's medical diagnosis (ICD-10 diagnosis codes) and the medical procedures performed on them (CPT and HCPCS procedure codes).
• Familiarity with payment, coding and reimbursement policies and utilization management tools that are used in managed care organizations.
• Demonstrated experience in technical writing on clinical topics.
• Familiarity with QuickBase
• Familiarity with TeamSite or other web content management systems.
• Assist with editing and web publication of clinical policies, as needed; ability to do basic web publication tasks when both staff involved in web publication are unavailable.
• Facility in use of generative artificial intelligence tools; participate in development and testing of AI tools for clinical policy
• Willingness to complete other administrative tasks as needed.

Responsibilities

• Develop evidence-based medical policies for Aetna, known as Clinical Policy Bulletins (CPBs).
• Respond to inquiries from Aetna medical directors and clinical staff regarding the medical necessity and proven value of specific items and services eligible for coverage under Aetna's medical benefit plans, emphasizing scientific evidence and supporting rationale.
• Address questions about the appropriate interpretation, application, and implementation of the CPBs.
• Revise and update the CPBs based on new clinical evidence or other relevant information.
• Collaborate with internal teams to ensure alignment of Aetna CPBs with organizational goals and processes.
• Research and provide rapid responses to clinical questions from Aetna medical directors or other clinical staff regarding the medical necessity and experimental and investigational status of interventions that are eligible for coverage under Aetna medical plans, considering published evidence, systematic evidence reviews, clinical practice guidelines, consensus statements, and technology assessments.
• Develop and update clinical policies (CPBs) on the experimental and investigational status and medical necessity of technologies eligible for coverage under Aetna medical plans, as well as clinical criteria for their use.
• Complete any additional tasks as directed by supervisor or manager.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees