Senior Clinical Strategist - Aetna Payment Integrity – Ideation & Affordability

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.

Position Summary
The Clinical Strategist, Payment Integrity – Ideation & Affordability will identify, evaluate, and advance innovative opportunities to improve healthcare affordability, payment accuracy, and clinical integrity.

Working at the intersection of clinical expertise, healthcare data, reimbursement, coding, medical policy, Payment Integrity, and business strategy, this role will translate emerging medical expense trends, clinical practices, coding and reimbursement changes, policy developments, healthcare utilization patterns, and industry intelligence into actionable Payment Integrity opportunities.

The Clinical Strategist will apply clinical and coding expertise to evaluate potential payment vulnerabilities, identify opportunities for new or enhanced clinical and payment controls, and develop concepts supported by clinical evidence, policy, claims data, and financial opportunity.

This role will collaborate across Payment Integrity and with Medical Policy, Clinical, Analytics and Decision Science, Technology, Operations, Product, Compliance, SIU, Network, Provider organizations, and vendor partners to move opportunities from initial idea through validation, business-case development, prioritization, governance, and implementation readiness.

Work Location

This position supports a remote/hybrid work model and is open to candidates residing within the contiguous United States. Candidates located in the Hartford, CT area will be expected to work onsite at Aetna’s Hartford headquarters as part of a hybrid work schedule.

Key Responsibilities

Clinical & Affordability Ideation

• Identify emerging clinical, medical expense, reimbursement, utilization, coding, and healthcare trends that may create opportunities to improve affordability, payment accuracy, or clinical integrity.
• Develop new Payment Integrity concepts using clinical expertise, claims experience, medical policy, coding guidance, industry intelligence, and data-driven insights.
• Evaluate existing clinical and Payment Integrity programs to identify potential gaps, leakage, enhancements, or expansion opportunities.
• Assess emerging treatments, technologies, procedures, and reimbursement practices for potential Payment Integrity implications.
• Translate complex clinical and coding issues into clearly defined business problems and actionable affordability opportunities.

Concept Development & Opportunity Validation

• Develop structured hypotheses and concept definitions for potential Payment Integrity solutions.
• Evaluate concepts for clinical validity, coding and reimbursement applicability, policy alignment, member and provider considerations, operational feasibility, and potential financial opportunity.
• Partner with Analytics and Decision Science resources to define appropriate datasets, populations, claims logic, analytical requirements, opportunity sizing, and testing approaches.
• Review claim examples and analytical findings to determine whether patterns represent valid clinical or payment opportunities.
• Develop business cases and recommendations that allow leadership to make informed decisions regarding investment and prioritization.
• Define clinical and business requirements that support the transition of validated concepts into solution development.

Clinical Strategy, Coding & Research

• Monitor changes in clinical practice, CPT/HCPCS/ICD coding, reimbursement methodologies, medical policy, regulatory requirements, healthcare technology, and emerging treatment patterns.
• Research industry practices, payer approaches, external intelligence, and innovations that may create new affordability opportunities.
• Evaluate relationships among clinical evidence, coding guidance, medical policy, reimbursement methodology, claims behavior, and Payment Integrity controls.
• Apply clinical and coding expertise to evaluate existing or proposed Payment Integrity methodologies.
• Serve as a clinical and coding subject matter resource during ideation, concept development, analytical validation, and governance discussions.

Cross-Functional Collaboration

• Partner across Medical Policy, Clinical, Pharmacy, Network, Provider, SIU, Analytics/Decision Science, Technology, Operations, Product, Compliance, and Payment Integrity.
• Facilitate discussions that bring clinical, analytical, operational, technological, and business perspectives together around potential affordability opportunities.
• Collaborate with internal teams and external Payment Integrity partners to understand existing capabilities, identify gaps, and explore new opportunities.

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