CVS Health

Clinical Team Lead

CVS Health  •  $67k - $143k/yr  •  United States (Onsite)  •  1 hour ago
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Job Description

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.

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.

Key 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



Required Qualifications

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.


Preferred Qualifications
• Exceptional Communication skills

• Effective time management skills

• Highly organized, ability to multi-task

Education

Must have active and unrestricted RN licensure in state of residence.

Associates Degree minimum, Bachelor's Degree preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$66,575.00 - $142,576.00

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

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.


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

We anticipate the application window for this opening will close on: 08/31/2026

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

CVS Health

About CVS Health

CVS Health is the leading health solutions company, delivering care like no one else can. We reach more people and improve the health of communities across America through our local presence, digital channels and over 300,000 dedicated colleagues.

Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by simplifying health care one person, one family and one community at a time. Follow @CVSHealth on social media.

Industry
Healthcare & Social Services
Company Size
10,000+ employees
Headquarters
Woonsocket, RI
Year Founded
1963
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