Description

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

May reside anywhere in the US

Position Summary

The Behavioral Health Medical Policy Lead is responsible for the identification, development, and execution of behavioral health clinical and payment policies, ensuring alignment with evidence-based guidelines, regulatory requirements, and enterprise affordability goals.

This role serves as a subject matter expert (SME) bridging clinical policy, coding, and claims adjudication by translating behavioral health policy intent into clear business requirements that drive accurate configuration and enforcement within claims processing platforms.

The position partners across Medical Policy, Medical Coding, Compliance, and vendor teams to ensure policy is operationalized consistently across end-to-end claims workflows (intake, edits, adjudication, denials, and appeals).

Behavioral Health Policy Identification & Development

• Lead identification of new and emerging behavioral health policy opportunities, including:

• Utilization management gaps
• Medical correct coding vulnerabilities
• Payment integrity risks

• Interpret clinical evidence, regulatory guidance, and industry best practices to:

• Develop or revise behavioral health medical policies
• Define coverage criteria, limitations, and exclusions

• Ensure policies are clinically sound, evidence-based, and aligned with CMS/state guidance

Payment Policy & Claims Editing Strategy

• Define and drive payment policy strategies to ensure accurate claim adjudication and cost containment
• Translate behavioral health policy intent into:

• Claims editing logic
• Correct coding requirements (DX, CPT/HCPCS, modifiers, frequency rules)
• Adjudication outcomes (deny, pend, allow, PA requirement)

• Partner with payment integrity and vendor teams (e.g., editing engines) to implement scalable solutions

Business Requirements Development (BRDs)

• Own development of detailed Business Requirements Documents (BRDs) to support policy implementation, including:

• Policy intent and business objectives
• Coding and clinical logic
• Claims system behavior across adjudication points
• Configuration and testing requirements

• Ensure requirements are:

• Clear, actionable, and testable
• Aligned with claims platform capabilities (e.g., ACAS, QNXT, HRP)

• Act as the primary liaison between clinical SMEs and technical/configuration teams

Claims Adjudication & Operational Integration

• Partner with claims operations to ensure policy is correctly implemented across:

• Front-end edits
• Pre-payment edits
• Post-adjudication processes

• Validate that behavioral health policies are correctly translated into system logic and medical coding rules
• Support testing, defect resolution, and go-live readiness

Quality Assurance, Compliance & Audit Readiness

• Perform policy QA and validation to ensure:

• Alignment between clinical intent and system execution
• Compliance with federal/state regulations and payer requirements

• Support audits and remediation efforts by:

• Identifying gaps in policy, medical coding, or configuration
• Driving corrective actions

Cross-Functional Leadership & Governance

• Serve as Behavioral Health SME across:

• Medical Policy governance forums
• Payment policy and vendor edit workgroups

• Partner with:

• Clinical teams (BH providers, UM)
• Medical coding SMEs
• Compliance and legal
• IT and vendor partners
• Lead end-to-end policy lifecycle from intake through execution and monitoring

Required Qualifications

• 7+ years of experience in medical policy, payment policy, or correct coding; behavioral health clinical practice; or utilization management
• Ability to interpret behavioral health clinical standards and translate into policy
• Apply correct coding frameworks (ICD-10, CPT/HCPCS) in policy and claims contexts
• Develop business requirements documents (BRDs) supporting claims system configuration
• Strong knowledge of behavioral health services (e.g., psychiatry, SUD, therapy modalities) and medical necessity criteria and utilization management
• Experience translating policy into medical coding logic (ICD-10, CPT, HCPCS), claims editing and adjudication rules
• Demonstrated experience developing business requirements (BRDs) for system implementation
• Experience with claims adjudication platforms and/or vendor editing solutions

Preferred Qualifications

• Experience with Medicaid and/or Medicare behavioral health policy
• Experience with payment integrity vendors (e.g., Cotiviti, Optum, ClaimsXten)

• Strong background in policy governance, audit/remediation and process improvement / Lean methodologies
• Formal training or coursework in healthcare policy or health economics, clinical informatics or data analytics and/or utilization management or population health
• Ability to effectively influence cross-functional teams without formal authority

Education

• Bachelor's degree in behavioral health or related field
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) (aligns with medical policy + coding roles) required and/or obtained within one year of start date in role

Pay Range

The typical pay range for this role is:

$67,900.00 - $182,549.00

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.

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: 07/28/2026

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