Senior Clinical Strategist - Aetna Payment Integrity – Ideation & Affordability

CVS Health • Hartford, CT

7d • $95,738 - $206,206 • Hybrid

About The Position

The Clinical Strategist, Payment Integrity – Ideation & Affordability identifies, evaluates, and advances opportunities to improve healthcare affordability, payment accuracy, and clinical integrity. Working across clinical expertise, healthcare data, reimbursement, coding, medical policy, Payment Integrity, and business strategy, the role turns emerging medical expense trends, clinical practices, coding and reimbursement changes, policy developments, utilization patterns, and industry intelligence into actionable opportunities.

The position applies clinical and coding expertise to assess payment vulnerabilities, develop new or enhanced controls, and build concepts supported by clinical evidence, policy, claims data, and financial opportunity. It collaborates with internal teams and external partners to move opportunities from ideation through validation, business-case development, prioritization, governance, and implementation readiness.

The role supports a remote/hybrid work model and is open to candidates in the contiguous United States. Candidates in the Hartford, Connecticut area are expected to work onsite at Aetna’s Hartford headquarters as part of a hybrid schedule.

Requirements

• Active, unrestricted clinical license in an applicable healthcare discipline, such as RN, NP, LPN, or PA; RN is preferred.
• Current nationally recognized professional coding certification, such as CPC, CCS, CCS-P, CIC, COC, or a comparable credential.
• At least 5 years of relevant healthcare experience, such as managed care, Payment Integrity, clinical operations, medical policy, utilization management, reimbursement, coding, claims, or healthcare analytics.
• Demonstrated experience in Payment Integrity, medical policy, claims editing, clinical validation, coding validation, or healthcare affordability.
• Knowledge of clinical terminology, medical coding, claims, reimbursement, and healthcare payment methodologies.
• Ability to interpret and apply clinical evidence, coding guidance, medical policy, and reimbursement requirements when evaluating claims and Payment Integrity concepts.
• Experience identifying, evaluating, or developing healthcare affordability, payment, clinical, coding, or operational improvement opportunities.
• Experience developing business cases, recommendations, concepts, or strategic initiatives.
• Ability to translate clinical and healthcare information into business strategies and actionable opportunities.
• Experience working across clinical, analytical, operational, technical, and business teams.
• Ability to communicate complex healthcare concepts effectively to clinical, technical, operational, and executive audiences.
• Strong research, critical-thinking, analytical, problem-solving, and communication skills.
• Education: Master’s degree or equivalent experience; BSN preferred. Under CVS policy, an associate’s degree requires 4 additional years of experience, and a bachelor’s degree requires 2 additional years of experience.

Nice To Haves

• Registered Nurse (RN).
• Experience evaluating medical-cost trends or identifying medical-cost savings opportunities.
• Experience working with claims analytics, clinical analytics, or healthcare data.
• Experience partnering with Payment Integrity vendors or healthcare technology organizations.
• Familiarity with Medicare, Commercial, and/or Medicaid reimbursement and regulatory environments.
• Experience researching emerging clinical technologies, procedures, pharmaceuticals, or treatment patterns and assessing their financial or reimbursement implications.
• BSN.

Responsibilities

• Identify emerging clinical, medical expense, reimbursement, utilization, coding, and healthcare trends that may improve affordability, payment accuracy, or clinical integrity.
• Develop Payment Integrity concepts using clinical expertise, claims experience, medical policy, coding guidance, industry intelligence, and data-driven insights.
• Evaluate existing clinical and Payment Integrity programs for gaps, leakage, enhancements, or expansion opportunities.
• Assess emerging treatments, technologies, procedures, and reimbursement practices for Payment Integrity implications.
• Translate complex clinical and coding issues into defined business problems and actionable affordability opportunities.
• Develop structured hypotheses and concept definitions for potential Payment Integrity solutions.
• Evaluate concepts for clinical validity, coding and reimbursement applicability, policy alignment, member and provider considerations, operational feasibility, and financial opportunity.
• Partner with Analytics and Decision Science to define datasets, populations, claims logic, analytical requirements, opportunity sizing, and testing approaches.
• Review claim examples and analytical findings to determine whether patterns represent valid clinical or payment opportunities.
• Develop business cases and recommendations to support leadership investment and prioritization decisions.
• Define clinical and business requirements for transitioning validated concepts into solution development.
• Monitor changes in clinical practice, coding, reimbursement methodologies, medical policy, regulations, healthcare technology, and emerging treatment patterns.
• Research industry practices, payer approaches, external intelligence, and innovations that may create affordability opportunities.
• Evaluate the relationships among clinical evidence, coding guidance, medical policy, reimbursement methodology, claims behavior, and Payment Integrity controls.
• Apply clinical and coding expertise to evaluate existing or proposed Payment Integrity methodologies and serve as a subject matter resource during ideation, validation, and governance.
• Partner with Medical Policy, Clinical, Pharmacy, Network, Provider, SIU, Analytics and Decision Science, Technology, Operations, Product, Compliance, Payment Integrity, and external partners.
• Facilitate discussions that integrate clinical, analytical, operational, technological, and business perspectives.
• Communicate clinical, coding, financial, and strategic considerations to clinical and non-clinical stakeholders.
• Develop and present concise, executive- and governance-ready recommendations.
• Support Payment Integrity Ideation & Affordability intake, evaluation, and governance processes.
• Prepare recommendations defining the opportunity, proposed solution, clinical rationale, evidence, estimated financial opportunity, dependencies, risks, and next steps.
• Support prioritization based on value, clinical validity, feasibility, strategic alignment, provider and member impact, and implementation considerations.
• Track concepts from initial idea through research, validation, prioritization, development, and implementation readiness.
• Provide clinical and coding perspectives during governance discussions and help resolve questions affecting concept viability.

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources to support colleagues and their families, based on eligibility.
• Eligibility for a CVS Health bonus, commission, or short-term incentive program in addition to base pay.

What This Job Offers

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