Senior Clinical Strategist – UM Program Integrity, Duals, Medicare

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🔥 0 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $87k - $187.5k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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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

• Execute routine and non-routine clinical and operational support tasks for UM Program Integrity • Serve as a subject matter expert in Medicare and Duals utilization management operations, including prior authorization and concurrent review • Interpret regulatory, operational, and business requirements into workflows, job aids, team resources, and practical guidance • Partner with compliance, operations, clinical, physician, and systems teams to support accurate, compliant utilization management processes • Identify workflow gaps, operational risks, and improvement opportunities affecting quality, turnaround time, data integrity, and execution readiness • Support and lead process enhancements, regulatory updates, system changes, and workflow improvements • Contribute to audit, accreditation, submission, and compliance readiness activities • Develop and maintain tools, reference materials, educational resources, and process documentation • Support letter-related and authorization-related process improvement, automation, workflow redesign, and Medicare/Duals transition work • Collaborate across teams to improve end-to-end utilization management execution • Guide colleagues through consultation, mentoring, and collaborative leadership • Communicate updates, risks, recommendations, and operational impacts to leaders and partners

🎯 Requirements

• Strong Medicare and Duals knowledge required • Strong utilization management experience required, including both prior authorization and concurrent review • Demonstrated experience working in a highly regulated healthcare environment with strong understanding of compliance, quality, and operational expectations • Experience partnering across clinical, operational, compliance, and business teams to implement process improvements and resolve complex workflow issues • Problem solving and decision making skills • Collaboration and teamwork skills • Execution and delivery skills • Strong written and verbal communication skills • Ability to develop practical tools, workflow guidance, and team resources that improve execution and consistency • RN and/or Behavioral Health license in good standing with no restrictions preferred • Experience supporting Medicare and Duals letter workflows, denial language review, or related member communication processes preferred • Experience with audit, accreditation, submission, or regulatory readiness work preferred • Experience supporting automation, system enhancement, or workflow redesign initiatives preferred • Bachelor’s Degree preferred

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program in addition to base pay