Health Services Manager (IC)- Medicaid and Duals – Aetna Medical Policy & Program Solutions

CVS Health; United States; Remote; USD 60,000 - 133,000; Full time

Job summary

CVS Health is seeking a Health Services Manager to lead quality projects within the Medical Policy & Program Solutions Team. This fully remote role requires significant expertise in Medicaid and Duals, focusing on enhancing healthcare quality and managing cross-functional initiatives. Ideal candidates will possess industry knowledge and strong collaboration skills.

Benefits

Affordable medical plan options

401(k) plan with company contributions

Employee stock purchase plan

No-cost wellness programs

Paid time off and flexible schedules

Qualifications

• Minimum 3 years' Medicaid and Duals experience.
• Certified Professional Coder within 2 years of hire.

Responsibilities

• Leads multiple health care quality projects and initiatives.
• Develops and implements business plans for Medical Policy & Program Solutions.
• Collaborates with functional and business managers.

Skills

Healthcare insurance and industry standard expertise

Compliance regulations understanding

Proficient in Microsoft Excel, Word, PowerPoint

Education

Associate or bachelor's degree in healthcare management

Job description

Health Services Manager (IC)- Medicaid and Duals – Aetna Medical Policy & Program Solutions

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.

Position Summary

The Health Services Manager is a key member of the Medical Policy & Program Solutions Team. The Health Service Manager will manage and influence health care quality projects and initiatives through design, development, and implementation. These activities enable Aetna to improve health care quality products, services, and processes by partnering across business units to meet business needs and accomplish goals.

This is a fully remote position. Eligible candidates will live anywhere in the contiguous United States.

Key Responsibilities

• Leads the work and deliverables of multiple, complex programs, and supports new business initiatives, that impact multiple process, systems, functions, and products related to authorizations services.
• Develops and implements business plans to achieve business goals for Medical Policy & Program Solutions.
• Collaborates and partners with other functional managers, other business areas/across the segments or other business areas.
• Develop and implement innovative ideas that support work/teams.
• Assist others to identify solutions to issues that negatively impact program and/or project plan.
• Lead and support scorable action items across Medicaid, Duals, and/or nationally.
• Develops documentation templates and systems to support projects and initiatives.

Required Qualifications

• Healthcare insurance and industry standard expertise
• Minimum 3 years' Medicaid and Duals experience to include understanding of compliance regulations, state Medicaid billing & coding guidelines.
• Medicaid and Duals internal audit and/or CMS Audits experience
• Proficient in Microsoft Excel, Word, and Power Point
• Certified Professional Coder through AAPC or AHIMA (Physician, Facility or Payer) within 2 years of hire

Preferred Qualifications

• Code editing and quality review experience related to payment policies, projects, and programs.
• QuickBase applications
• QNXT Claim review and expertise on claim adjudication with knowledge of SQL query.
• Familiar with AMA CPT/HCPCS codes, ICD-10 Codes, State Medicaid Policies and NCD/LCD’s.
• Project Management experience a plus or experience managing internal projects.
• Medicaid and Duals product experience with a plus for
• ClaimsXten or Cotiviti PPM/Coding Validation or Optum ER LOC experience or expertise

Education

Associate or bachelor’s degree in healthcare management or equivalent managed care experience in the healthcare industry

Anticipated Weekly Hours

40

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.

Position Summary

The Health Services Manager is a key member of the Medical Policy & Program Solutions Team. The Health Service Manager will manage and influence health care quality projects and initiatives through design, development, and implementation. These activities enable Aetna to improve health care quality products, services, and processes by partnering across business units to meet business needs and accomplish goals.

This is a fully remote position. Eligible candidates will live anywhere in the contiguous United States.

Key Responsibilities

• Leads the work and deliverables of multiple, complex programs, and supports new business initiatives, that impact multiple process, systems, functions, and products related to authorizations services.
• Develops and implements business plans to achieve business goals for Medical Policy & Program Solutions.
• Collaborates and partners with other functional managers, other business areas/across the segments or other business areas.
• Develop and implement innovative ideas that support work/teams.
• Assist others to identify solutions to issues that negatively impact program and/or project plan.
• Lead and support scorable action items across Medicaid, Duals, and/or nationally.
• Develops documentation templates and systems to support projects and initiatives.

Required Qualifications

• Healthcare insurance and industry standard expertise
• Minimum 3 years' Medicaid and Duals experience to include understanding of compliance regulations, state Medicaid billing & coding guidelines.
• Medicaid and Duals internal audit and/or CMS Audits experience
• Proficient in Microsoft Excel, Word, and Power Point
• Certified Professional Coder through AAPC or AHIMA (Physician, Facility or Payer) within 2 years of hire

Preferred Qualifications

• Code editing and quality review experience related to payment policies, projects, and programs.
• QuickBase applications
• QNXT Claim review and expertise on claim adjudication with knowledge of SQL query.
• Familiar with AMA CPT/HCPCS codes, ICD-10 Codes, State Medicaid Policies and NCD/LCD’s.
• Project Management experience a plus or experience managing internal projects.
• Medicaid and Duals product experience with a plus for
• ClaimsXten or Cotiviti PPM/Coding Validation or Optum ER LOC experience or expertise

Education

Associate or bachelor’s degree in healthcare management or equivalent managed care experience in the healthcare industry

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$60,300.00 - $132,600.00

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.

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 people

We 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 06/07/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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