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CVS Health Durable Medical Equipment Clinical Consultant in Dallas, Texas

Job Description

Conducts clinical reviews and provides input and oversight for clinical policy implementation for a medical specialty (e.g. Prosthetics/Orthotics). Participates in the development, implementation, and evaluation of clinical programs that are specific to that medical discipline. Excludes nursing, physician, behavioral health, dental, pharmacy and physical/occupational therapy roles which are reflected in alternate job descriptions.

Fundamental Components

  • Determines medical necessity and appropriateness (may include prospective, concurrent, retrospective review/analysis of program submissions, claims)

  • Provides clinical expertise for medical discipline for preservice reviews and reviews of claim determinations and in support of program and benefit utilization and improvements goals

  • Consults and lends clinical expertise to colleagues and other internal and external constituents

  • Utilizes clinical experience and skills in a collaborative process across the Enterprise to evaluate and facilitate appropriate healthcare services/benefits for members

  • Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment

  • Educates and empowers colleagues at all levels to enable decision making at most appropriate level.

  • Render opinions on emerging specialty trends, utilization review, plan coverage, network management, claims policy and standards of care and develop, implement, and evaluate policies and procedures, which meet business needs

Background Experience

  • 3+ years clinical practice experience, e.g. hospital, professional practice.

  • Assistive Technology Certification

  • Seating & Mobility Specialist Certification

  • Managed care/claims review experience preferred

Education

Master's degree

Percent of Travel Required

0 - 10%

Business Overview

Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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