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.Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.Under the direction of the Lead Clinical Psychologist, this position will focus on utilization, quality, and review of fraud, waste, and abuse for individual Aetna member cases.Expectations/Responsibilities:
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- Review and prepare cases for medical necessity review of ABA.
- Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
- Make recommendation for enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
- Serve as a clinical SME supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases. Completion of Fraud waste and abuse reviews in partnership with SIU
- Provide SME support to enterprise-wide initiatives supporting members with neurodevelopmental disorders
- Use available resources and technology in developing evidence, supporting allegations of fraud and abuse.
- Research and prepare cases for clinical and legal review.
- Provide day-to-day support and guidance for ABA prior authorization clinical team and the health plan medical directors.
- Attend and participate in clinical meetings with care management and utilization management. Provide subject matter expertise on all ABA-related questions and member issues.
- Support provider education initiatives for providers with a neurodiverse specialty including quality assurance and Fraud waste and abuse issues.
- Active, current, and unencumbered licensure in the field of psychology.
- Minimum of five (5) years post-graduate experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
- Direct experience providing treatment in the Autism space (e.g., ABA, NDBI, EIBI)
- BCBA or BCBA-D credential
- Experience with and knowledge of CPT and HCPCS coding guidelines and principles
- Experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
- PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology
40Time Type
Full timePay Range
The typical pay range for this role is:$100,425.00 - $216,300.00This 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 peopleWe 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.