Description

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.

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.

Under the direction of the Senior Manager, Behavioral Health, this position will focus on utilization, with support of and expectation to cross train into quality review for individual cases for members across Aetna

Expectations/Responsibilities:

• Reviews and prepares cases for medical necessity review of ABA.
• Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
• Serves as a clinical SME supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
• Conducts clinical quality assurance audits of provider charts and review of key policies and procedures assuring consistent use of audit tools and internal policies
• Consistently collaborates with Senior SIU Medical Director, Senior QA Medical Director and BH Clinical Quality Lead Director
• Providers SME support to enterprise-wide initiatives supporting members with neurodevelopmental disorders
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Provides day-to-day support and guidance for ABA prior authorization clinical team and the health plan medical directors.
• Attends and participates in clinical meetings with care management and utilization management. Provides subject matter expertise on all ABA-related questions and member issues.
• Supports provider education initiatives for providers with a neurodiverse specialty including quality assurance and Fraud waste and abuse issues.

Required Qualifications:

• Five (5) or more years of experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
• PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology
• Direct experience providing treatment in the Autism space (e.g., ABA, NDBI, EIBI)

Preferred:

• Experience with and knowledge of CPT and HCPCS coding guidelines and principles
• Experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.

Education:

• Active and current state license(s) without encumbrances, including 5 years of post-graduate direct patient care experience.
• BCBA or BCBA-D credential

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$110,467.00 - $237,930.00

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 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: 06/17/2026

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