Health Services Professional

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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 primary responsibility of this position is to develop evidence‑based medical policies for Aetna, known as Clinical Policy Bulletins (CPBs). The individual will respond to inquiries from Aetna medical directors and clinical staff regarding the medical necessity and proven value of specific items and services eligible for coverage under Aetna's medical benefit plans, emphasizing scientific evidence and supporting rationale. Additionally, the role involves addressing questions about the appropriate interpretation, application, and implementation of the CPBs.

The individual will also be responsible for revising and updating the CPBs based on new clinical evidence or other relevant information. Furthermore, the individual will collaborate with internal teams to ensure alignment of Aetna CPBs with organizational goals and processes. This position reports to the Aetna Medical Affairs Executive Director of the Clinical Policy Unit and works directly with other colleagues on the Clinical Policy Unit Team, as well as colleagues across Medical Affairs.

• Strong understanding of evidence‑based medicine and health technology assessment.
• Deep understanding of methodological principles of clinical study design and statistical methods used in clinical research.
• Facility with Pub Med database search engine for accessing published, peer‑reviewed medical literature.

• Evaluating the methodological quality of clinical studies.
• Conducting literature searches and summarizing the results.
• Desktop Tools - Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Excel.
• Excellent communication skills: this includes written and verbal skills.
• Superior writing skills that require moderate to minimal editing, and proficiency in technical writing.
• Excellent time management and multi‑tasking skills.

• Conduct rapid reviews using Pub Med and other relevant clinical evidence resources to identify evidence relevant to the safety and effectiveness of a clinical intervention, identify the highest quality evidence, summarize the results of each of those studies, and reach conclusions about the overall quality of evidence in support of the intervention.
• Research and provide rapid responses to clinical questions from Aetna medical directors or other clinical staff regarding the medical necessity and experimental and investigational status of interventions that are eligible for coverage under Aetna medical plans, considering published evidence, systematic evidence reviews, clinical practice guidelines, consensus statements, and technology assessments.
• Develop and update clinical policies (CPBs) on the experimental and investigational status and medical necessity of technologies eligible for coverage under Aetna medical plans, as well as clinical criteria for their use.
• Candidate is required to have regular and predictable attendance.
• Candidate will be required to complete any additional tasks as directed by supervisor or manager.

• Prior relevant work experience related to evidence‑based clinical policy development.
• Broad knowledge of clinical medicine, including drugs, biologics, devices, surgical procedures, tests, and therapies.
• Basic understanding of commercial health insurance and Medicare and Medicaid programs.
• Basic understanding of the regulatory environment for medical technologies, including the FDA approval process and Medicare coverage determinations.
• Basic understanding of the system of standardized codes used in the billing and tracking of…