Senior Manager, Behavioral Health

CVS Health

1d•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. Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. Under the direction of the Executive Director, this position will lead efforts to best support our members with neurodevelopmental disorders across the organization. This position is fully remote. Fully remote. Eligible candidates can live anywhere in the United States.

Requirements

Five (5) or more years of experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
Five (5) or more years administrative experience in the health care industry or managed care
PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology or behavior analysis
Experience in providing clinical guidance and input in the business analytic building process.
Active and current BCBA or Psychology state license without encumbrances

Nice To Haves

Experience with and knowledge of CPT and HCPCS coding guidelines and principles
Direct experience with ABA Utilization management, clinical chart reviews, and fraud/waste/ abuse investigations

Responsibilities

Leads a team of PhDs who prepare and review Applied Behavior Analysis (ABA) service provision for medical necessity.
Reviews and prepares cases for medical necessity review of ABA.
Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
Responsible for overall medical policies of the unit to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of ABA/Psychology team.
Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
Leads clinical staff in the coordination of quality care.
Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Serves as a clinical subject matter expert supporting Special Investigative Unit Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste, or abuse.
Providers subject matter expert support to enterprise-wide initiatives supporting members with neurodevelopmental disorders
Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Researches and prepares cases for clinical and legal review.