Senior Manager, Health Services - Aetna Medicaid Payment Policy

CVS Health•Work At Home-Oklahoma, OK

3d•$67,900 - $149,328•Remote

About The Position

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 payment policy writers professionals plus coordinates payment policies for Aetna Medicaid across 15 State Health Plans. This position will work closely with the Health Plan Governance to support each states specific requirements, documentation, compliance and regulations. The position is fully remote. Eligible candidates may reside anywhere in the contiguous United States.

Requirements

5+ years of payment policy experience in the health care industry
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

Nice To Haves

Experience with state Medicaid Regulation/Guidelines
Bachelor’s degree in healthcare administration, communications or related field - or equivalent experience

Responsibilities

Ensures compliance with healthcare regulations and policies for state Medicaid and Duals line of business as it related to payment policies.
Facilitate cross-functional policy committees and manage implementation of committee decisions across all lines of business
Manage MPPS Policy Project Management team of policy writers
Oversee all policy project work including monitoring & tracking of progress of status updates and communications.
Manage resource utilization within and across policy team
Partner with vendor partners to implement policy solutions including creation of editing logic, drafting of test scenarios and publication of policy language.
Support the operational processes of the Medicaid Health Policy Governance
Monitor status reports to ensure effective workflow and timely development of coding and payment policies
Support internal departments and processes in the development and implementation of policies and procedures
Ensure all medical policies are compliant with relevant regulations and are consistent across all lines of business
Participate in department initiatives, scorable action items, and projects
Work with health plan business leaders and corporate leaders to develop deliverables on policy priorities
Provide medical coding and payment policies deliverables for Medicaid and Duals and other markets as business needs change
Work with business product owners, government relations, and compliance leads to monitor legislative and regulatory activities for potential impact on existing or proposed policies
Collaborate with interdisciplinary team members to achieve team goals
Perform any other job duties as requested