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. **Position Summary** 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 Lead Director, Service Operations, this position will focus on utilization, quality and fraud waste and abuse review for individual cases for members across Aetna . This role is fully remote. Eligible candidates must be licensed in Arizona and live in the greater Phoenix area. Expectations/Responsibilities: + Reviews and prepares cases for medical necessity review of Applied Behavior Analysis (ABA). + Provide input into medical management programs/policies that pertain to neurodevelopmental disorders. + Make recommendation for enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols. + Serves as a clinical SME supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases Completion of Fraud waste and abuse reviews in partnership with SIU. + 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** + Greater Phoenix, Arizona area resident + National Board Certified Behavior Analyst-Doctoral (BCBA-D) and unencumbered license by the Arizona Board of Psychologist Examiners to practice as a Behavior Analyst + Five years of post-graduate direct patient care experience. + 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) + Ability to travel up to10% for mandatory office meetings and local travel **Preferred Qualifications** + 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** Doctoral degree (Ph.D. or equivalent) in a field related to behavior analysis **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** The typical pay range for this role is: $100,425.00 - $216,300.00 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: 11/01/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.