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.

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.

Under the direction of the Executive Director, this position will lead efforts to best support our members with neurodevelopmental disorders across the organization.

This position is fully remote. Fully remote. Eligible candidates can live anywhere in the United States.

Expectations/Responsibilities:

• Leads a team of PhDs who prepare and review Applied Behavior Analysis (ABA) service provision for medical necessity.
• Reviews and prepares cases for medical necessity review of ABA.
• Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
• Responsible for overall medical policies of the unit to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of ABA/Psychology team.
• Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
• Leads clinical staff in the coordination of quality care.
• Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
• Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
• Serves as a clinical subject matter expert supporting Special Investigative Unit Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
• Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste, or abuse.
• Providers subject matter expert support to enterprise-wide initiatives supporting members with neurodevelopmental disorders
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.

Required Qualifications:

• Five (5) or more years of experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
• Five (5) or more years administrative experience in the health care industry or managed care
• PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology or behavior analysis
• Experience in providing clinical guidance and input in the business analytic building process.
• Active and current BCBA or Psychology state license without encumbrances

Preferred:

• Experience with and knowledge of CPT and HCPCS coding guidelines and principles
• Direct experience with ABA Utilization management, clinical chart reviews, and fraud/waste/ abuse investigations

Education:

• PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology or behavior analysis
• Active and current state license without encumbrances.

Pay Range

The typical pay range for this role is:

$99,420.00 - $261,723.00

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. This position also includes an award target in the company's equity award program.

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: 05/07/2026

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