Clinical Team Lead

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.

Summary 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.

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