Sr. Principal Clinical Leader - Aetna MI and IL Integrated Plans - RN or BH

Position Summary

The Duals segment is a significant driver of profitable growth within government programs at Aetna. Continued growth in this segment will require sustainable approaches to scaling a compliant, efficient and effective clinical care management operation. To provide this leverage and support, F/HIDE SNP clinical operations require focused leadership and accountability to manage a complex regulatory environment and a challenging operation that includes 500+ staff and multiple vendor partners.

The Senior Principal Clinical Leader provides strategic leadership and operational oversight for clinical care management across Aetna's Michigan and Illinois Integrated Plans.

Location

This role is fully remote. Eligible candidates may live anywhere in the contiguous United States but preference will be given to applicants living in Michigan.

Travel

This role will require up to 10% travel for conferences, auditing, and stakeholder visitations.

Fundamental Components & Physical Requirements

Lead the strategic growth and enhancement of applicable CM program capabilities

• Inform model of care and workflow best practice in the development of new technology platforms and tools
• Collaborates with executive leadership throughout the organization to develop and implement program strategies that meet business, CMS, federal and state regulations as well as accrediting agency requirements
• Responsible for cross-functional integration of care and case management, utilization management, program operations with core
• Responsible for cost savings and quality improvement projects through successful implementation.
• Leads and manages all aspects of projects and/or programs. Ensures the use of a formal project plan and collaborative workgroups are used in demonstrating the achievement of the project implementation goals.

Deliver operational performance and compliance

• Accountable for relationship management with relevant state authorities and the development, vetting and reporting of state compliance and quality measures and achievement of measure goals.
• Accountable for managing processes, communication and results of internal and external processes.
• Leads a team that promotes high standards of operational practice through advancement of policies, procedures, practice guidelines and alignment of clinical and business processes and practices
• Responsible for the implementation and revision of medical management letters ensuring that letters are compliant with CMS, federal and state regulations as well as accrediting entities.
• Responsible for relationship management for vendors; ensures targets are achieved and medical management goals are met.

Manage operations staff and develop workforce and organization

• Lead recruitment and operating model development to meet operational growth needs;
• Develop and implement staffing models that are consistent, cost effective and meet all compliance obligations.
• Oversee all workforce and operational readiness needs related to clinical system migrations / implementations.
• Lead, develop, motivate and manage a high performing team to meet organizational goals and objectives while effectively managing change.
• Lead effectively in a matrixed environment with critical business functions provided by shared service divisions (eg Engagement Hubs, Member Service Operations)
• Lead a virtually integrated staff (including clinical and non-clinical members) within multiple geographic markets.
• Foster an environment that supports professional development, mobility and operational

Required Qualifications

• Active unrestricted clinical license in applicable functional area. (e.g. RN, LCPC, LCSW)
• 10+ years Managed Care experience required; Medicare and Medicaid including LTSS and DSNP, highly preferred
• 7+ years of Care Management operations and leadership experience, including leading leaders and developing high-performing teams.
• Leading change in a growth business
• Experience leading the strategic design, execution, and outcomes management of Care Management programs, with a demonstrated ability to drive clinical and financial performance.
• Experience planning, leading and organizing the resources of a large and growing team and developing talent.

Preferred Qualifications

• Ability to synthesize program performance and clinical outcome
• Ability to evaluate and interpret data for the purpose of developing new programs and processes to meet business demands
• Ability to communicate in a highly effective manner with internal and external constituents in both written and oral format

Education & Licensure

• If Behavioral Health - Master's degree in a field leading to independent Behavioral Health licensure
• If Registered Nurse - Masters' degree or equivalent* experience, MSN preferred.

*Equivalent years of experience defined by CVS Policy: If candidate has associate’s degree, additional 4 years of experience is needed. If candidate has bachelor’s degree, an additional 2 years of experience is required.

$123,857.00 - $266,770.00 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. This position also includes an award target in the company’s equity award program.

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.

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

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