Manager, Clinical Health Services – LTSS Service Decision Review

CVS Health

Service Decision Review Manager overseeing LTSS service authorization and compliance for Aetna Better Health of Virginia. Leading a team to ensure accurate and timely service reviews.

Posted 5/22/2026full-timeRemote • Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $87,035 - $187,460 per yearWebsite

About the role

Key responsibilities & impact

Provides direct leadership and oversight of LTSS service authorization and decision review operations, including initial, concurrent, and retrospective reviews.
Ensures compliance with DMAS requirements, contractual obligations, CMS regulations, and internal medical management policies.
Oversees timely and accurate issuance of Notices of Action, ensuring regulatory timeframes, content, and member rights are met.
Leads and supports appeal review processes, including preparation of clinical rationales, file reviews, and collaboration with Medical Directors and Appeals teams.
Establishes and monitors performance expectations related to productivity, timeliness, quality, and compliance outcomes.
Recruits, hires, coaches, and develops staff, supporting a culture of accountability, consistency, and continuous improvement.
Utilizes data and audit findings to identify trends, risks, and opportunities for process improvement.
Escalates quality, compliance, and regulatory concerns through established governance channels.
Serves as a clinical resource and subject matter expert for LTSS service authorization policy interpretation.
Communicates effectively with internal and external stakeholders, including state partners, in both written and verbal formats.
Leads change initiatives and process enhancements to improve member experience, decision accuracy, and operational efficiency.
Ensures all administrative and people management responsibilities are completed in accordance with company standards.

Requirements

What you’ll need

Active and unrestricted Virginia Registered nurse license
5+ years of clinical experience
3+ years of LTSS service authorization, utilization management, or service decision review experience
2+ years of supervisory or people leadership experience
Demonstrated knowledge of LTSS service authorization criteria, Notice of Action requirements, and member appeal rights
Experience with Medicaid programs and DMAS Medicaid Enterprise System (MES)
Strong analytical skills with the ability to interpret data and apply findings to operational improvements
Proficiency with MS Office applications and virtual work environments

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

LTSS service authorizationutilization managementclinical rationalesdata analysisprocess improvementcompliance monitoringperformance managementregulatory complianceclinical experiencesupervisory experience

Soft Skills

leadershipcoachingcommunicationcollaborationaccountabilityorganizational skillsanalytical skillsproblem-solvingchange managementcontinuous improvement

Certifications

Virginia Registered Nurse license