Senior Clinical Strategist - Aetna Payment Integrity – Ideation & Affordability

CVS Health•Hartford, CT

6d•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. The role combines clinical and coding expertise with healthcare data, reimbursement, medical policy, Payment Integrity, and business strategy to translate clinical, coding, utilization, reimbursement, policy, and industry trends into actionable opportunities. The strategist evaluates potential payment vulnerabilities and develops concepts supported by clinical evidence, policy, claims data, and financial analysis. The role collaborates across Payment Integrity and with Medical Policy, Clinical, Analytics and Decision Science, Technology, Operations, Product, Compliance, SIU, Network, Provider organizations, and vendor partners to move ideas through research, validation, business-case development, prioritization, governance, and implementation readiness. This position supports a remote/hybrid work model and is open to candidates residing within the contiguous United States. Candidates in the Hartford, CT 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 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.
Master’s degree or equivalent experience. Equivalent experience provisions state that candidates with an associate’s degree need 4 additional years of experience, and candidates with a bachelor’s degree need 2 additional years of experience.

Nice To Haves

Registered Nurse (RN).
BSN preferred.
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.

Responsibilities

Identify emerging clinical, medical expense, reimbursement, utilization, coding, and healthcare trends that may create affordability, payment accuracy, or clinical integrity opportunities.
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, CPT/HCPCS/ICD coding, reimbursement methodologies, medical policy, regulatory requirements, healthcare technology, and treatment patterns.
Research industry practices, payer approaches, external intelligence, and innovations that may create affordability opportunities.
Evaluate relationships among clinical evidence, coding guidance, medical policy, reimbursement methodology, claims behavior, and Payment Integrity controls.
Apply clinical and coding expertise to assess 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/Decision Science, Technology, Operations, Product, Compliance, and Payment Integrity teams.
Facilitate discussions that combine clinical, analytical, operational, technological, and business perspectives around affordability opportunities.
Collaborate with internal teams and external Payment Integrity partners to understand capabilities, identify gaps, and explore opportunities.
Communicate clinical, coding, financial, and strategic considerations to clinical and non-clinical stakeholders.
Develop and present clear, concise, executive- and governance-ready recommendations.
Support Payment Integrity Ideation & Affordability intake, evaluation, and governance processes.
Prepare recommendations that define the opportunity, proposed solution, clinical rationale, supporting evidence, estimated financial opportunity, dependencies, risks, and next steps.
Support opportunity prioritization based on value, clinical validity, feasibility, strategic alignment, provider/member impact, and implementation considerations.
Maintain visibility into concepts as they progress 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.