Manager, Clinical Health Services - LTSS Service Decision Review - Aetna Better Health of VA

CVS Health•Work At Home-Virginia, VA

5d•$87,035 - $187,460•Remote

About The Position

The Service Decision Review Manager is a key clinical leader for Aetna Better Health of Virginia and is responsible for oversight of LTSS service authorization decision-making, Notice of Action compliance, and appeal readiness. This role leads a high-performing team responsible for timely, accurate, and compliant service reviews in alignment with DMAS, contractual, and regulatory requirements. This position reports to the Sr Principal Clinical Leader and partners closely with Medical Directors, Appeals, Quality, and Operations leadership. This is a remote position. Eligible candidates must reside in the State of Viriginia.

Requirements

Active and unrestricted Virginia Registered nurse license
5+ years of clinical experience.
3+ years of LTSS service authorization, utilization management, or service decision review experience.
2+ years of supervisory or people leadership experience.
Demonstrated knowledge of LTSS service authorization criteria, Notice of Action requirements, and member appeal rights.
Experience with Medicaid programs and DMAS Medicaid Enterprise System (MES).
Strong analytical skills with the ability to interpret data and apply findings to operational improvements.
Proficiency with MS Office applications and virtual work environments.

Nice To Haves

Direct experience supporting LTSS populations within Medicaid managed care.
Working knowledge of medical management regulations, DMAS policies, and audit expectations.
Experience supporting appeal hearings or fair hearings.
Certified Case Manager (CCM) or similar certification.

Responsibilities

Provides direct leadership and oversight of LTSS service authorization and decision review operations, including initial, concurrent, and retrospective reviews.
Ensures compliance with DMAS requirements, contractual obligations, CMS regulations, and internal medical management policies.
Oversees timely and accurate issuance of Notices of Action, ensuring regulatory timeframes, content, and member rights are met.
Leads and supports appeal review processes, including preparation of clinical rationales, file reviews, and collaboration with Medical Directors and Appeals teams.
Establishes and monitors performance expectations related to productivity, timeliness, quality, and compliance outcomes.
Recruits, hires, coaches, and develops staff, supporting a culture of accountability, consistency, and continuous improvement.
Utilizes data and audit findings to identify trends, risks, and opportunities for process improvement.
Escalates quality, compliance, and regulatory concerns through established governance channels.
Serves as a clinical resource and subject matter expert for LTSS service authorization policy interpretation.
Communicates effectively with internal and external stakeholders, including state partners, in both written and verbal formats.
Leads change initiatives and process enhancements to improve member experience, decision accuracy, and operational efficiency.
Ensures all administrative and people management responsibilities are completed in accordance with company standards.