Sr Clinical Consultant - Wheelchair DME

Connecticut, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must possess an Assistive Technology Professional (ATP) or Seating Mobility Specialist (SMS) certification from RESNA. A Bachelor's degree or equivalent, 7-10 years of clinical practice experience, and one or more years of health plan/payor experience are required. Eligibility for a state license as a physical or occupational therapist is also necessary. Proficiency in Microsoft Word and Excel is expected.

Responsibilities

The Sr Clinical Consultant - Wheelchair DME will provide clinical expertise and business direction for medical management programs, focusing on quality care and payment policy. Responsibilities include supporting the appeal process, clinical claim review, pre-certification, and predetermination of benefits across commercial, Medicare, and Medicaid environments. The role involves participating in workgroups to improve healthcare services, applying clinical coding and reimbursement expertise to ensure policy alignment, and using data analysis for quality improvement initiatives. The consultant will act as a subject matter expert and internal consultant, contributing to payment policy, and collaborating with diverse teams to manage business objectives.

Skills

Clinical Expertise

Medical Management Programs

Clinical Policy

Payment Policy

Appeals

Claim Review

Reimbursement

Coding

Pre-certification

Predetermination of Benefits

Commercial Insurance

Medicare

Medicaid

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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