Clinical Team Lead

Job not on LinkedIn

🔥 0 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $66.6k - $142.6k / year

⏰ Full Time

🟠 Senior

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

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

• Own the hands-on execution of root cause investigation and corrective action implementation within a specific line of business and appeal type. • Conduct detailed root cause analysis on assigned L2/L3 addressable opportunities — including individual case review, 5 Whys documentation, and pattern identification. • Research specific RCA issues (e.g., RCA 408 Novologix auth match issues, RCA 542 late contract loading, RCA 566 Medicare drug E/I denials) through case-level deep dives. • Document root causes with supporting case examples, impacted volumes, and LOB breakdowns (Medicare Par, Medicare MNP, Commercial). • Execute agreed corrective actions within your function — working directly with operational teams, system owners, and upstream partners. • Validate that addressable volumes are impacted by implemented changes, with support from Analytical Support. • Compare pre- and post-implementation appeal and overturn trends to confirm corrective action effectiveness. • Participate in twice-weekly Workstream Touchpoints, providing case-level updates and surfacing emerging patterns.

🎯 Requirements

• 5+ years in healthcare appeals processing, claims adjudication, utilization management, medical policy, or coding — depending on workstream assignment • For clinical SMEs: clinical credentials or deep working knowledge of UM review criteria, medical necessity determination, CPB/LCD/NCD application, or coding edit rules (E&M, incidental, mutually exclusive) • Hands-on experience investigating individual appeal cases and tracing denial root causes across systems • Ability to work across LOBs — understanding differences between Medicare Par, Medicare MNP, and Commercial appeal handling • Strong documentation skills for RCA write-ups and corrective action tracking • Must have active and unrestricted RN licensure in state of residence.

🏖️ Benefits

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