Clinical Program Consultant - Individual Performance Assurance

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.

The Performance Assurance Team, as part of the Aetna Clinical Solutions, Clinical Insights and Performance Optimization Team, is expanding our team and services.

Overview:

The Clinical Program Consultant position will collaborate with vendor leadership and the UM Programmatic Performance Assurance Team to identify opportunities to improve program performance. This position's role is to act as an advocate for and support business objectives by ensuring optimal member experience through evaluating the quality and effectiveness of the clinical member touchpoints, with a focus on nurse decision making.

Responsibilities:

The Clinical Program Consultant will be responsible for conducting audits, identifying areas of improving audit process, identifying trends and
areas of opportunity and process improvement recommendations. Scope of work includes the aspects of a Service Authorization that applies
to the Nurse Decision related to a claim. This could include intake, UM, precertification, clinical claim review, appeals. Responsible for providing analysis, presentation, and other support materials within areas of expertise; and developing new areas of expertise. Develop relationships with internal peers, external consultants and cross-functional team members as required in support of Performance Assurance programs. The Clinical Program Consultant must be innovative and not afraid to challenge existing ways of working to continuously
improve and enhance the member experience. Adaptability and flexibility will be required as the Performance Assurance team is expanding its services. Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Required Qualifications:

• 3-5 years managed care experience, including strong diverse Utilization Review experience, i.e. Utilization Management, Precertification,
• Registered Nurse that must hold an unrestricted license in their state of residence.
• Demonstrated ability to communicate effectively.
• Demonstrated ability to collaborate
• Time efficient and highly organized.
• Strong Microsoft Office Suite skills

Preferred Qualifications:

• Clinical Claim Review, Appeals
• Project management experience
• Demonstrated ability to report out to leadership
• Experience working cross functionally, auditing, analyzing data and reporting out results.

Education:

Bachelor of Science in Nursing (BSN) required

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$88,374.00 - $190,344.00

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: 09/21/2025

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