Senior Manager, Health Services - Aetna Medical Policy and Program Solutions - Registered Nurse

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. At Aetna®, part of CVS Health, we proudly serve more than 26 million medical members through our broad range of health plan offerings. We're committed to delivering a simpler, more meaningful, and personal health care experience to each of them. As a key member of the Medical Policy & Program Solutions team, the Senior Manager, Health Services plays a critical role in supporting Aetna members and the business by leading clinical and claims-focused initiatives that drive program effectiveness, regulatory compliance, and cost management across Medicaid and Duals lines of business. This role manages a cross-functional team of health services professionals and coordinates claim editing opportunities, clinical program enhancements, savings initiatives, and vendor implementation efforts. The position is fully remote. Eligible candidates may reside anywhere in the contiguous United States.

Required Qualifications

• 5–7 years of relevant work experience
• Active, unrestricted Registered Nurse (RN) license in state of residence
• Certified Professional Coder (AAPC or AHIMA), including Physician, Facility, or Payer certification
• 1–2 years of project management experience
• 3–5 years of claims and policy support experience in the healthcare industry; managed care experience preferred
• Minimum of 3 years of Medicaid and/or Duals experience, including code editing, policy development, and understanding of state guidelines
• Strong verbal and written communication skills
• Experience performing root cause analysis and identifying actionable solutions
• Experience conducting claims analytics to validate industry standards
• Familiarity with claim editing software and the ability to propose system changes
• Demonstrated ability to meet project milestones and negotiate for resources
• High level of proficiency with the Microsoft Office suite, including advanced Excel skills
• Experience with Lyric ClaimsXten and/or Cotiviti PPM and Coding Validation tools

Preferred Qualifications

• Experience with state Medicaid Regulation/Guidelines
• Experience with QNXT Claim System

Education Registered Nurse required; bachelor’s degree preferred Pay Range The typical pay range for this role is: $75,400.00 - $182,549.00 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: 04/11/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job