Clinical Team Lead

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

About the Role

Own the hands-on execution of root cause investigation and corrective action implementation within a specific line of business and appeal type. You are the subject matter expert closest to the actual appeal cases — researching individual RCAs, documenting findings, executing fixes, and validating that changes are reducing overturn volumes. This role bridges the gap between analytical findings and operational remediation.

Responsibilities

• Root Cause Investigation
  • 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)
  • Support root cause of clinical appeals for Commercial UM/MPO/Coding
• Corrective Action Execution
  • Execute agreed corrective actions within your function — working directly with operational teams, system owners, and upstream partners
  • Coordinate with relevant partners: Network/Provider Contracting for rate issues, MPPS for payment policy changes, UM COE for clinical workflow modifications, EviCore for third-party review process changes
  • Track implementation milestones and provide regular updates on status, roadblocks, risks, and issues
• Impact Validation
  • 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
  • Flag cases where expected impact is not materializing and investigate contributing factors
• Participation in Governance
  • Participate in twice-weekly Workstream Touchpoints, providing case-level updates and surfacing emerging patterns
  • Agree to corrective action timelines and deliverables with the Workstream Lead
  • Contribute domain expertise to the identification of new addressable opportunities beyond the current 14 L2 drivers

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

Qualifications

• Associates Degree minimum, Bachelor's Degree preferred
• Exceptional communication skills
• Effective time management skills
• Highly organized, ability to multi-task

Pay

The typical pay range for this role is $66,575.00 - $142,576.00. This pay range represents the 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.

Schedule

• Anticipated weekly hours: 40
• Time type: Full time

Benefits

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility

Additional details about available benefits are provided during the application process and on Benefits Moments.