Health Services Professional

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

This is a fully remote, work from home role.

The primary responsibility of this position is to create evidence-based medical policies for Aetna (known as Clinical Policy Bulletins or CPBs).  You will also be responsible for responding to inquiries from Aetna medical directors and other clinical staff on whether specific items and services that eligible for coverage under Aetna medical benefit plans are medically necessary and of proven value, with particular emphasis on the scientific evidence and supporting rationale. Respond to the Aetna clinical staff on queries about the appropriate interpretation, application, and implementation of the Aetna CPBs. Be responsible for revising and updating the Aetna CPBs considering new clinical evidence or other relevant information. 

This position reports to the Aetna Medical Affairs Executive Director of the Clinical Policy Unit and works directly with other colleagues on the Clinical Policy Unit Team, as well as colleagues across Medical Affairs.

In this role you will:

• Respond to questions from medical directors and other clinical staff on clinical policy issues
• Drafting new clinical policies and revise existing clinical policies and present those revisions to Clinical Policy Council
• Periodically update existing clinical policies.
• Review evidence submissions from product manufacturers and providers
• Ad hoc projects and administrative tasks as needed
• Conduct rapid reviews using PubMed and other relevant clinical evidence resources to identify evidence relevant to the safety and effectiveness of a clinical intervention, identify the highest quality evidence, summarize the results of each of those studies, and reach conclusions about the overall quality of evidence in support of the intervention.
• Research and provide rapid responses to clinical questions from Aetna medical directors or other clinical staff regarding the medical necessity and experimental and investigational status of interventions that are eligible for coverage under Aetna medical plans, considering published evidence, systematic evidence reviews, clinical practice guidelines, consensus statements, and technology assessments.
• Develop and update clinical policies (CPBs) on the experimental and investigational status and medical necessity of technologies eligible for coverage under Aetna medical plans, as well as clinical criteria for their use.
• Candidate is required to have regular and predictable attendance.
• Candidate will be required to complete any additional tasks as directed by supervisor or manager.

Required Qualifications:

• Minimum three years’ experience with clinical policy creation
• Minimum one year experience with medical writing
• Minimum one year experience with PubMed database search engine for accessing published, peer-reviewed medical literature
• Evidence-based medicine and health technology assessments
• Understanding of methodological principles of clinical study design and statistical methods used in clinical research

Preferred Qualifications:

• Minimum eight years’ experience with clinical policy creation

• Prior relevant work experience related to evidence-based clinical policy development.
• Broad knowledge of clinical medicine, including drugs, biologics, devices, surgical procedures, tests, and therapies.
• Basic understanding of commercial health insurance and Medicare and Medicaid programs.
• Basic understanding of the regulatory environment for medical technologies, including the FDA approval process and Medicare coverage determinations
• Basic understanding of the system of standardized codes used in the billing and tracking of healthcare services to report a patient's medical diagnosis (ICD-10 diagnosis codes) and the medical procedures performed on them (CPT and HCPCS procedure codes).

Education:

Master’s or above in public health, basic health-related science, or healthcare fields.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$95,738.00 - $206,206.00

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: 07/31/2025

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