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. At Aetna®, part of CVS Health, we proudly serve more than 26 million medical members through our broad range of health plan offerings. We're committed to delivering a simpler, more meaningful, and personal health care experience to each of them. As a key member of the Medical Policy & Program Solutions team, the Senior Manager, Health Services plays a critical role in supporting Aetna members and the business by leading clinical and claims-focused initiatives that drive program effectiveness, regulatory compliance, and cost management across Medicaid and Duals lines of business. This role manages a cross-functional team of health services professionals and coordinates claim editing opportunities, clinical program enhancements, savings initiatives, and vendor implementation efforts. The position is fully remote. Eligible candidates may reside anywhere in the contiguous United States.
Requirements
- 5–7 years of relevant work experience
- Active, unrestricted Registered Nurse (RN) license in state of residence
- Certified Professional Coder (AAPC or AHIMA), including Physician, Facility, or Payer certification
- 1–2 years of project management experience
- 3–5 years of claims and policy support experience in the healthcare industry; managed care experience preferred
- Minimum of 3 years of Medicaid and/or Duals experience, including code editing, policy development, and understanding of state guidelines
- Strong verbal and written communication skills
- Experience performing root cause analysis and identifying actionable solutions
- Experience conducting claims analytics to validate industry standards
- Familiarity with claim editing software and the ability to propose system changes
- Demonstrated ability to meet project milestones and negotiate for resources
- High level of proficiency with the Microsoft Office suite, including advanced Excel skills
- Experience with Lyric ClaimsXten and/or Cotiviti PPM and Coding Validation tools
- Registered Nurse required; bachelor’s degree preferred
Nice To Haves
- Experience with state Medicaid Regulation/Guidelines
- Experience with QNXT Claim System
Responsibilities
- Leads clinical and claims-focused initiatives that drive program effectiveness, regulatory compliance, and cost management across Medicaid and Duals lines of business.
- Manages a cross-functional team of health services professionals
- Coordinates claim editing opportunities, clinical program enhancements, savings initiatives, and vendor implementation efforts.
Benefits
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
