Senior Clinical Strategist - Aetna Payment Integrity – Ideation & Affordability

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.

Position Summary
The Clinical Strategist, Payment Integrity – Ideation & Affordability will identify, evaluate, and advance innovative opportunities to improve healthcare affordability, payment accuracy, and clinical integrity.

Working at the intersection of clinical expertise, healthcare data, reimbursement, coding, medical policy, Payment Integrity, and business strategy, this role will translate emerging medical expense trends, clinical practices, coding and reimbursement changes, policy developments, healthcare utilization patterns, and industry intelligence into actionable Payment Integrity opportunities.

The Clinical Strategist will apply clinical and coding expertise to evaluate potential payment vulnerabilities, identify opportunities for new or enhanced clinical and payment controls, and develop concepts supported by clinical evidence, policy, claims data, and financial opportunity.

This role will collaborate across Payment Integrity and with Medical Policy, Clinical, Analytics and Decision Science, Technology, Operations, Product, Compliance, SIU, Network, Provider organizations, and vendor partners to move opportunities from initial idea through validation, business-case development, prioritization, governance, and implementation readiness.

Work Location

This position supports a remote/hybrid work model and is open to candidates residing within the contiguous United States. Candidates located in the Hartford, CT area will be expected to work onsite at Aetna’s Hartford headquarters as part of a hybrid work schedule.

Key Responsibilities

Clinical & Affordability Ideation

• Identify emerging clinical, medical expense, reimbursement, utilization, coding, and healthcare trends that may create opportunities to improve affordability, payment accuracy, or clinical integrity.
• Develop new Payment Integrity concepts using clinical expertise, claims experience, medical policy, coding guidance, industry intelligence, and data-driven insights.
• Evaluate existing clinical and Payment Integrity programs to identify potential gaps, leakage, enhancements, or expansion opportunities.
• Assess emerging treatments, technologies, procedures, and reimbursement practices for potential Payment Integrity implications.
• Translate complex clinical and coding issues into clearly defined business problems and actionable affordability opportunities.

Concept Development & Opportunity Validation

• Develop structured hypotheses and concept definitions for potential Payment Integrity solutions.
• Evaluate concepts for clinical validity, coding and reimbursement applicability, policy alignment, member and provider considerations, operational feasibility, and potential financial opportunity.
• Partner with Analytics and Decision Science resources to define appropriate datasets, populations, claims logic, analytical requirements, opportunity sizing, and testing approaches.
• Review claim examples and analytical findings to determine whether patterns represent valid clinical or payment opportunities.
• Develop business cases and recommendations that allow leadership to make informed decisions regarding investment and prioritization.
• Define clinical and business requirements that support the transition of validated concepts into solution development.

Clinical Strategy, Coding & Research

• Monitor changes in clinical practice, CPT/HCPCS/ICD coding, reimbursement methodologies, medical policy, regulatory requirements, healthcare technology, and emerging treatment patterns.
• Research industry practices, payer approaches, external intelligence, and innovations that may create new affordability opportunities.
• Evaluate relationships among clinical evidence, coding guidance, medical policy, reimbursement methodology, claims behavior, and Payment Integrity controls.
• Apply clinical and coding expertise to evaluate existing or proposed Payment Integrity methodologies.
• Serve as a clinical and coding subject matter resource during ideation, concept development, analytical validation, and governance discussions.

Cross-Functional Collaboration

• Partner across Medical Policy, Clinical, Pharmacy, Network, Provider, SIU, Analytics/Decision Science, Technology, Operations, Product, Compliance, and Payment Integrity.
• Facilitate discussions that bring clinical, analytical, operational, technological, and business perspectives together around potential affordability opportunities.
• Collaborate with internal teams and external Payment Integrity partners to understand existing capabilities, identify gaps, and explore new opportunities.
• Effectively communicate clinical, coding, financial, and strategic considerations to both clinical and non-clinical stakeholders.
• Develop and present clear, concise, executive/governance-ready recommendations supporting opportunity evaluation and decision-making.

Ideation & Affordability Governance

• Support the Payment Integrity Ideation & Affordability intake, evaluation, and governance process.
• Develop recommendations that clearly define the problem or opportunity, proposed solution, clinical rationale, supporting evidence, estimated financial opportunity, dependencies, risks, and recommended next steps.
• Support prioritization of opportunities based on potential value, clinical validity, feasibility, strategic alignment, provider/member impact, and implementation considerations.
• Maintain visibility into concepts as they progress from initial idea through research, validation, prioritization, development, and implementation readiness.
• Provide clinical and coding perspectives during governance discussions and help resolve questions affecting concept viability.

Required Qualifications

• Active, unrestricted clinical license in an applicable healthcare discipline (e.g., RN, NP, LPN, PA). Registered Nurse (RN) preferred.

• Current nationally recognized professional coding certification, such as CPC, CCS, CCS-P, CIC, COC, or comparable credential.
• Minimum 5 years of relevant healthcare experience (e.g., managed care, payment integrity, clinical operations, medical policy, utilization management, reimbursement, coding, claims, or healthcare analytics).
• Demonstrated experience in payment integrity, medical policy, claims editing, clinical validation, coding validation, or healthcare affordability.
• Demonstrated knowledge of clinical terminology, medical coding, claims, reimbursement, and healthcare payment methodologies.
• Ability to interpret and apply clinical evidence, coding guidance, medical policy, and reimbursement requirements when evaluating healthcare claims and Payment Integrity concepts.
• Experience identifying, evaluating, or developing healthcare affordability, payment, clinical, coding, or operational improvement opportunities.
• Experience developing business cases, recommendations, concepts, or strategic initiatives.
• Demonstrated ability to translate clinical and healthcare information into business strategies and actionable opportunities.
• Experience working across clinical, analytical, operational, technical, and business teams.
• Ability to communicate complex healthcare concepts effectively to clinical, technical, operational, and executive audiences.
• Strong research, critical-thinking, analytical, problem-solving, and communication skills.

Preferred Qualifications

• Registered Nurse (RN)

• Experience evaluating medical-cost trends or identifying medical-cost savings opportunities.
• Experience working with claims analytics, clinical analytics, or healthcare data.
• Experience partnering with payment integrity vendors or healthcare technology organizations.
• Familiarity with Medicare, Commercial, and/or Medicaid reimbursement and regulatory environments.
• Experience researching emerging clinical technologies, procedures, pharmaceuticals, or treatment patterns and assessing their financial or reimbursement implications.

Education

Master’s degree or equivalent* experience – BSN preferred

*Equivalent years of experience defined by CVS Policy: If candidate has associate’s degree, additional 4 years of experience is needed. If candidate has bachelor’s degree, an additional 2 years of experience is required.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

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

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