Position 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.

Key Responsibilities

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 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.

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: 08/31/2026