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Position Summary
The Service Decision Review Manager is a key clinical leader for Aetna Better Health of Virginia and is responsible for oversight of LTSS service authorization decision-making, Notice of Action compliance, and appeal readiness. This role leads a high-performing team responsible for timely, accurate, and compliant service reviews in alignment with DMAS, contractual, and regulatory requirements.
This position reports to the Sr Principal Clinical Leader and partners closely with Medical Directors, Appeals, Quality, and Operations leadership.
This is a remote position. Eligible candidates must reside in the State of Viriginia.
Position Responsibilities
- 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.
Required Qualifications
- 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.
Preferred Qualifications
- Direct experience supporting LTSS populations within Medicaid managed care.
- Working knowledge of medical management regulations, DMAS policies, and audit expectations.
- Experience supporting appeal hearings or fair hearings.
- Certified Case Manager (CCM) or similar certification.
Education
Master's degree or equivalent experience in clinical area of expertise (e.g. bachelor's degree plus 7 years' experience; associate's degree or RN diploma plus 9 years' experience).
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$87,035.00 - $187,460.00
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.
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.
Great benefits for great people
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.
We anticipate the application window for this opening will close on: 06/20/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Additional Information
Company: CVS Health
Location: Virginia
Salary: $87035.00 - $187460.00 per year
Job ID: R0894177
Specialties: Case Manager, Utilization Management, Appeals Nurse
Required Licenses: RN
Experience Level: 5-10 years
