Health Services Manager; IC), Evaluation & Management Policy Management – Aetna MPPS

Position Summary

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.

The Health Services Manager is a key member of the Medical Policy & Program Solutions (MPPS) team supporting the Evaluation & Management (E&M) Program. This individual contributor role is responsible for managing and influencing health care quality projects and initiatives that support E&M Program objectives. These activities enable Aetna to improve health care quality products, services, and processes by partnering across business units to meet business needs and accomplish strategic goals.

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

• Leads the work and deliverables of multiple, complex programs, and supports business initiatives, that impact multiple processes, systems, functions, and products.
• Identify and validate the appropriate medical, coding, reimbursement, and pre-payment policies applicable to each request.
• Ensure deviation recommendations align with policy intent, clinical guidelines, contractual obligations, and regulatory requirements.
• Conduct quality reviews to validate policy alignment, decision accuracy, documentation integrity, and governance compliance.
• Perform periodic audits and implementation reviews to verify approved deviations are operationalized accurately.
• Develop reporting and performance metrics related to deviation volumes, turnaround times, approval outcomes, and quality performance.
• Analyze deviation trends, appeals, quality findings, and recurring exception requests to identify opportunities for policy clarification and process improvement.
• Lead initiatives focused on improving review consistency and strengthening controls.
• Collaborates and partners with other functional managers, other business areas/across the segments.
• Develop and implement innovative ideas that support work/teams.
• Assist others to identify solutions to issues that negatively impact program and/or project plan.
• Convert technical findings and complex data visualization into clear, actionable business strategies.

• 5+ years of medical, payment or clinical policy experience
• Certified Professional Coder (ie: CPC, CCS, RHIT)
• Experience with business analytics with focus on data analysis for decision-making
• Proficient in Microsoft Excel, Word, Power Point, Tableau and Power BI
• Ability to work independently, think creatively, and proactively identify process improvement and automation opportunities
• Exceptional written and verbal communication skills
• Demonstrated organizational and prioritization abilities
• Effective problem-solving and sound decision-making skills

• Certified Evaluation and Management Coder (CEMC)
• Familiarity or experience with Evaluation and Management
• Familiar with AMA CPT/HCPCS codes, ICD-10 Codes, Medicare Policies and NCD/LCD’s Code editing and quality review experience related to payment policies, projects, and programs
• Quick Base applications
• Project management

Bachelor’s degree or equivalent
* experience
* Equivalent years of experience defined by CVS Policy:
If candidate has associate’s degree, additional 2 years of experience is needed; if candidate has no degree, additional 4 years of experience is needed.

40

Full time

The typical pay range for this role is: $60,300.00 - $ 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…