Description

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 recognized as one of the oldest and largest national insurers. This extensive experience positions us uniquely to support the transformation of health care. We are committed to advancing a care system that is transparent, consumer-focused, and acknowledges physicians for their clinical excellence and effective utilization of health care resources.
Reporting to the Executive Behavioral Health Medical Director, Aetna Medicaid, this role is responsible for utilization, quality, and fraud, waste, and abuse reviews for individual cases involving members across Aetna.

Expectations and Responsibilities:
• Serve as the principal utilization management reviewer for cases related to Applied Behavior Analysis (ABA).
• Provide daily support and guidance to the ABA prior authorization clinical team and health plan medical directors.
• Attend and actively participate in clinical meetings with care management and utilization management teams, offering subject matter expertise on all ABA-related questions and member concerns.
• Contribute to the development and refinement of medical management programs and policies addressing neurodevelopmental disorders.
• Recommend enhancements to managed care review guidelines and clinical criteria, drawing on comprehensive knowledge of health care delivery systems, utilization methodologies, reimbursement models, and treatment protocols.
• Offer subject matter expert support for Medicaid-wide initiatives that benefit members with neurodevelopmental disorders.
• Support provider education initiatives for professionals specializing in neurodiversity, including quality assurance and issues related to fraud, waste, and abuse.

Required Qualifications:
• A minimum of five (5) years of clinical experience in the assessment and treatment of neurodevelopmental disorders, including, but not limited to, Autism Spectrum Disorder.
• Doctoral degree (PhD or PsyD) with a specialization in neurodevelopment and child and adolescent psychology.
• Direct experience providing treatment within the autism field, such as Applied Behavior Analysis (ABA), Naturalistic Developmental Behavioral Interventions (NDBI), or Early Intensive Behavioral Intervention (EIBI).

Preferred Qualifications:
• Demonstrated knowledge of, and experience with, Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding guidelines and principles.
• Experience utilizing clinical expertise to review medical records and determine claim payments in alignment with company, state, federal, and industry standard coding principles and guidelines.
• Primary state licensure in Virginia (VA), Louisiana (LA), and/or Oklahoma (OK), with the willingness and ability to obtain additional licensure as required.

Education and Credentials:
• Active and unrestricted state license(s), with a minimum of five (5) years of post-graduate direct patient care experience.
• Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst-Doctoral (BCBA-D) credential.

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: 11/21/2025

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