Sr Clinical Strategist – Aetna Medicaid Program Integrity – RN or BH
At CVS Health, we?re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation?s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues ? caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
The Senior Clinical Strategist is a leader within the Program Integrity Team for Medicaid Care Management. The Sr Clinical Strategist provides clinical leadership and oversight for the Aetna Medicaid Care Management division as related to data integrity and compliance at the national level and market level. This position collaboratively develops, tests, implements, supports, and monitors regulatory, compliance, and operational reports and dashboards. This position provides leadership and direction in the execution of the standard operating model for Care Management as well as state contractual requirements as they relate to reporting. This position will work collaboratively with the Informatics division to ensure that reporting is accurately reflecting the work being documented by care management team.
The Senior Clinical Strategist is a key conduit for contractual, policy, and process related information for ICM, LTSS and Children Specialty programming, initiatives, and processes. The incumbent is tasked with monitoring any new or revised state contracts, standard operating procedures, and desktops that would change how reporting functions. They will also act as a subject matter expert to build new reports and dashboards and will be utilized to lead user acceptance testing of reporting builds or revisions.
This is a fully remote role. Eligible candidates will live in the Eastern or Central Time Zones.
Core Duties
? Partner with Medicaid Care Management, NCQA, Compliance and Audit leads to analyze and support member universe reports at national and market levels.
? Works to establish and maintain collaborative relationships by fostering excellent customer response and appropriate problem resolution.
? Collaborates with leadership throughout the organization to develop and implement program strategies in meeting business objectives, as well as CMS, federal and state regulations, and accrediting agency requirements across the plans in a matrix environment.
? Demonstrates expertise in all care management processes to act as primary resource for informatics, compliance, and program oversite, consultation.
? Represents advanced level of knowledge and training related to system technology and data analytics for CM process integration.
? Oversee and ensure compliance with all applicable Federal and State regulations relevant to the plans function.
Required Qualifications
? 3+ years of experience in Medicaid Care Management, preferably in a managed care organization
? Must have active and unrestricted licensure in applicable functional area. RN or BH (or the like) in the state of candidate’s residence.
? 3+ years of demonstrated experience in managing large initiatives and projects.
? 3+ years of experience working collaboratively with internal and external teams to build knowledge and improve processes.
? 3+ years of experience in data analysis providing operational insights from data.
? 5+ years of experience successfully building, maintaining, and supporting effective relationship.
? 5+ years of experience in Microsoft Office Suite products including Word, Excel, Power Point and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail, and presentation software.
? Must be willing and able to travel up to 15% anywhere in US to attend on site meetings/trainings etc. on as need basis.
Preferred Qualifications
? Ability to manage multiple timelines and produce evidence of driving toward success with regular updates on progress in all areas of clinical informatics project or program management.
? Participate in strategic projects and process improvements based on lessons learned.
? Knowledge of medical management regulations, standards, and policies.
? Ability to evaluate and interpret data for the purpose of developing and revising new programs and processes to meet business demand across cross-functional teams to achieve goals and to improve plan outcomes.
? 5+ years of experience communicating with all levels of an organization from C-Suite executives to front-line staff (written and verbal).
? Profound understanding of clinical workflows and best practices.
? Ability to effectively manage expectations and inspire confidence.
? Knowledge of NCQA, policy and process development and ability to understand contract requirements.
? Knowledge of programming languages, able to use data analytics tools like Tableau, Power Bi, Access, QuickBase, or Power Query.
? LTSS experience
Education
Bachelor’s degree minimum
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The Typical Pay Range For This Role Is
$95,738.00 – $206,206.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great Benefits For Great People
We take pride in our comprehensive and competitive mix of pay and benefits ? investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
? 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.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 05/30/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Apply Job!
Apply to this Job