Principal Clinical Leader - Aetna OhioRISE UM

CVS Health

3d • Remote

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 The OhioRISE (Resilience through Integrated Systems and Excellence) program is a specialized Medicaid managed care initiative focused on providing and coordinating behavioral health services for eligible children and youth. The Principal Clinical Leader is a key member of the OhioRISE leadership team and is accountable for designing, standardizing, and continuously improving utilization management processes that support timely, compliant, and clinically appropriate decisions for a complex Medicaid population. Partners across clinical operations, quality, network, compliance, and plan leadership to translate requirements into clear workflows, sustainable staffing models, and measurable performance outcomes. Leads through influence and coaching, ensuring consistent execution, audit readiness, and an engaged clinical team culture. This is a fully remote position. Eligible candidates must reside within the state of Ohio.

Requirements

• 10+ years of progressive leadership experience, including significant experience in utilization management and/or managed care operations.
• Must live in Ohio
• Unencumbered license as a RN or master's level independent behavioral health clinician (e.g LISW, LIMFT, LPCC,)
• 3 year’s experience providing direct behavioral health care coordination or oversight for children and adolescents with complex behavioral health needs
• Demonstrated experience driving UM performance outcomes through metrics, operational reporting, and corrective action.
• Experience translating regulatory requirements into operational policies, procedures, and training.
• Strong stakeholder management and communication skills; able to influence across functions.
• 10% travel required

Nice To Haves

• Certification as a Certified Professional in Health Care Quality by the NAHQ or CHCQM by the American Board of Quality Assurance and Utilization Review Providers.
• If Behavioral Health: Master’s degree in a field leading to independent Behavioral Health clinical licensure (e.g LISW, LIMFT, LPCC)
• If Registered Nurse: Master’s degree or equivalent experience in clinical area of expertise (e.g. bachelor’s degree plus 7 years’ experience, associate’s degree or RN diploma plus 9 years’ experience).

Responsibilities

• OhioRISE UM operations leads the design, implementation, and continuous optimization of utilization management workflows to support timely, clinically sound decisions across behavioral health and related covered services.
• Establishes standard work, decision logic guidance, and clinical documentation expectations to improve consistency, reduce rework, and support regulatory readiness.
• Oversees performance monitoring and reporting (e.g., turnaround time, productivity, timeliness, quality, overturn rates, audit findings) and drives corrective actions when performance gaps emerge.
• Partners with Compliance, Quality, and other stakeholders to ensure policies and procedures align to CMS, NCQA, state Medicaid requirements, and plan-specific contractual expectations.
• Leads complex issue resolution and case escalation pathways, ensuring decisions and communications are clinically appropriate, well-documented, and defensible.
• Collaborates with cross-functional partners (operations, network, provider relations, appeals/grievances, care management, IT/product) to remove operational barriers and improve member/provider experience.
• Coaches and develops UM clinical leaders and individual contributors through clear expectations, timely feedback, and capability building (clinical judgment, documentation quality, productivity, and change adoption).
• Supports onboarding and training strategy for OhioRISE UM, ensuring readiness across new colleagues, process changes, and emerging requirements.
• Drives process improvement initiatives that simplify workflows, improve efficiency, and maintain high standards for safety and quality.
• Contributes to strategic planning for OhioRISE UM capacity, staffing models, and prioritization across competing initiatives and regulatory deliverables.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Principal