Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.Position Summary
At Aetna, our health benefits business, we are committed to helping our members achieve their best health in an affordable, convenient, and comprehensive manner. Combining the assets of our health insurance products and services with CVS Health's unrivaled presence in local communities and their pharmacy benefits management capabilities, we're joining members on their path to better health and transforming the health care landscape in new and exciting ways every day.Aetna is recruiting an Executive Director, Utilization Management (UM) Center of Excellence (COE) who will lead the development and execution of strategic initiatives that support UM operations, ensuring compliance with all regulations, optimizing performance, and delivering exceptional outcomes. This leader will oversee the precertification process, grievances and appeals management, turnaround time (TAT) adherence, and ensure the organization meets NCQA accreditation standards and state Medicaid requirements. This position is ideal for a visionary leader with broad-based expertise in UM, regulatory compliance, performance optimization, and operational excellence across diverse lines of business.You'll make an impact by:
Want more jobs like this?
Get jobs in Hartford, CT delivered to your inbox every week.
Leadership and Strategic Oversight
- Developing and leading a high-performing Center of Excellence (COE) team to support UM operations, ensuring best-in-class performance and member outcomes.
- Driving strategic initiatives to enhance UM processes, minimizing grievances and appeals, and ensuring compliance with all state, federal, and NCQA standards.
- Fostering a culture of collaboration, continuous improvement, and accountability.
- Maintaining expert knowledge of state Medicaid rules, NCQA accreditation requirements, and federal regulations to ensure operational compliance.
- Acting as the primary liaison with regulatory bodies during audits and assessments, ensuring audit preparedness and success.
- Establishing a robust framework for interpreting and operationalizing regulatory changes.
- Optimizing workflows, technology, and resources for efficient and accurate precertification, authorization processes, and appeals management.
- Leading initiatives to reduce grievances and appeals through root cause analysis, provider/member education, and policy adjustments.
- Overseeing learning and performance programs to ensure staff are well-equipped to meet operational goals.
- Establishing and monitoring key performance indicators (KPIs) for UM operations, including TATs, grievance/appeals rates, and member satisfaction metrics.
- Leveraging advanced analytics and dashboards to drive data-informed decision-making and continuous improvement.
- Providing regular reports and insights to senior leadership on UM outcomes, trends, and improvement opportunities.
- Driving adoption of innovative technologies, such as AI and machine learning, to streamline UM processes and enhance efficiency.
- Benchmarking against industry standards to identify and implement best practices.
- Fostering an organizational culture that values creativity, forward-thinking, and proactive problem-solving.
- Partnering with clinical teams to align UM strategies with broader care management and population health goals.
- Engaging providers to support network alignment with UM requirements, minimizing administrative burdens and improving efficiency.
- Working across internal teams to integrate UM processes across Medicaid, Medicare, and Commercial lines of business.
- Championing initiatives to improve member engagement and satisfaction, ensuring timely access to care and clear communication.
- Developing provider-friendly workflows and clear escalation pathways to enhance relationships and operational efficiency.
- Creating robust training programs for UM staff to ensure comprehensive knowledge of compliance, policies, and member/provider engagement strategies.
- Maintaining a centralized knowledge repository for regulatory guidelines, policy updates, and operational best practices.
- Implementing performance optimization initiatives that support staff development and operational excellence.
- Ensuring UM policies reflect cultural competence and address the needs of diverse populations, particularly underserved communities.
- Leading health equity initiatives to reduce disparities in care and outcomes.
- Supporting CVS Health in attracting, retaining, and engaging a diverse and inclusive consumer-centric workforce that delivers on our purpose and reflects the communities in which we work, live, and serve.
The candidate will have a strong work ethic, be a self-starter, and be able to be highly productive in a dynamic, collaborative environment. This position offers broad exposure to all aspects of the company's business, as well as significant interaction with all the business leaders. The candidate will be expected to have the following key attributes:
- 10+ years of leadership experience in utilization management, including precertification, grievances, and appeals.
- Expertise in NCQA standards, Medicaid regulations, and compliance management.
- Proven success in building and leading Centers of Excellence or similar operational support structures.
- Demonstrated ability to lead change management, develop high-performing teams, and foster a culture of innovation.
- Strong collaboration skills to engage with internal and external stakeholders, including regulatory agencies, providers, and members.
- Ability to work Hybrid Model (in office Tuesday / Wednesday / Thursday) if reside near an office, or work at home arrangement.
- Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.
Technical Proficiency
- Familiarity with UM-related software (e.g., MCG, InterQual) and data analytics platforms (e.g., Tableau, Power BI).
- Understanding of interoperability requirements and the role of data exchange in driving operational efficiencies.
- Bachelor's degree in healthcare administration, nursing, business, or a related field required; Master's degree preferred.
The typical pay range for this role is:$131,500.00 - $303,195.00
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. This position also includes an award target in the company's equity award program.
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit Benefits | CVS HealthWe anticipate the application window for this opening will close on: 03/03/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.