Manager, Clinical Health Services – LTSS Service Decision Review

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🕒 May 22

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $87k - $187.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Provides direct leadership and oversight of LTSS service authorization and decision review operations, including initial, concurrent, and retrospective reviews. • Ensures compliance with DMAS requirements, contractual obligations, CMS regulations, and internal medical management policies. • Oversees timely and accurate issuance of Notices of Action, ensuring regulatory timeframes, content, and member rights are met. • Leads and supports appeal review processes, including preparation of clinical rationales, file reviews, and collaboration with Medical Directors and Appeals teams. • Establishes and monitors performance expectations related to productivity, timeliness, quality, and compliance outcomes. • Recruits, hires, coaches, and develops staff, supporting a culture of accountability, consistency, and continuous improvement. • Utilizes data and audit findings to identify trends, risks, and opportunities for process improvement. • Escalates quality, compliance, and regulatory concerns through established governance channels. • Serves as a clinical resource and subject matter expert for LTSS service authorization policy interpretation. • Communicates effectively with internal and external stakeholders, including state partners, in both written and verbal formats. • Leads change initiatives and process enhancements to improve member experience, decision accuracy, and operational efficiency. • Ensures all administrative and people management responsibilities are completed in accordance with company standards.

🎯 Requirements

• Active and unrestricted Virginia Registered nurse license • 5+ years of clinical experience • 3+ years of LTSS service authorization, utilization management, or service decision review experience • 2+ years of supervisory or people leadership experience • Demonstrated knowledge of LTSS service authorization criteria, Notice of Action requirements, and member appeal rights • Experience with Medicaid programs and DMAS Medicaid Enterprise System (MES) • Strong analytical skills with the ability to interpret data and apply findings to operational improvements • Proficiency with MS Office applications and virtual work environments

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility