Clinical Team Lead

CVS Health

Clinical Team Lead at CVS Health executing root cause investigations and implementing corrective actions within healthcare appeals. Collaborating on the analysis of clinical appeal processes.

Posted 7/31/2026full-timeRemote • Connecticut • 🇺🇸 United StatesSenior💰 $66,575 - $142,576 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in root cause analysis and corrective action implementation within healthcare appeals processing, with a strong focus on documentation and cross-functional collaboration. Possesses clinical knowledge and active RN licensure to effectively navigate complex appeal cases and ensure compliance with medical necessity criteria.

Highest-signal resume keywords

Root Cause AnalysisHealthcare Appeals ProcessingCorrective Action ImplementationRN LicensureDocumentation Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Root Cause AnalysisClaims AdjudicationUtilization ManagementMedical PolicyCoding5 Whys DocumentationCase ReviewDenial TracingCorrective Action TrackingPattern Identification

Soft Skills

CollaborationCommunicationAnalytical ThinkingDetail Orientation

Certifications & Qualifications

Active RN Licensure

Industry Keywords

Medicare ParMedicare MNPCommercial AppealsMedical Necessity DeterminationCPBLCDNCDE&M CodingIncidental CodingMutually Exclusive Coding

About the role

Key responsibilities & impact

Own the hands-on execution of root cause investigation and corrective action implementation within a specific line of business and appeal type.
Conduct detailed root cause analysis on assigned L2/L3 addressable opportunities — including individual case review, 5 Whys documentation, and pattern identification.
Research specific RCA issues (e.g., RCA 408 Novologix auth match issues, RCA 542 late contract loading, RCA 566 Medicare drug E/I denials) through case-level deep dives.
Document root causes with supporting case examples, impacted volumes, and LOB breakdowns (Medicare Par, Medicare MNP, Commercial).
Execute agreed corrective actions within your function — working directly with operational teams, system owners, and upstream partners.
Validate that addressable volumes are impacted by implemented changes, with support from Analytical Support.
Compare pre- and post-implementation appeal and overturn trends to confirm corrective action effectiveness.
Participate in twice-weekly Workstream Touchpoints, providing case-level updates and surfacing emerging patterns.

Requirements

What you’ll need

5+ years in healthcare appeals processing, claims adjudication, utilization management, medical policy, or coding — depending on workstream assignment
For clinical SMEs: clinical credentials or deep working knowledge of UM review criteria, medical necessity determination, CPB/LCD/NCD application, or coding edit rules (E&M, incidental, mutually exclusive)
Hands-on experience investigating individual appeal cases and tracing denial root causes across systems
Ability to work across LOBs — understanding differences between Medicare Par, Medicare MNP, and Commercial appeal handling
Strong documentation skills for RCA write-ups and corrective action tracking
Must have active and unrestricted RN licensure in state of residence.

Benefits

Comp & perks

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