Amy Duvall
Atlanta,GA
Summary
Accomplished healthcare leader with expertise in clinical appeals operations at Aetna, a CVS Health Company. Proven track record in developing high-performing teams and implementing innovative programs. Skilled in interpreting clinical policy and regulatory standards, driving compliance and efficiency. Successfully managed complex appeals processes and enhancing team productivity.
Overview
2026
2026
years of professional experience
Work History
Principal Clinical Leader, Commercial Appeals Ops
Aetna, a CVS Health Company
11.2019 - Current
- Manage clinical operations for UM and Behavioral Health (BH) commercial member and provider clinical appeals
- Direct supervision of teams supporting commercial, IFP, and BH appeals
- Develop and implement new clinical programs
- Maintain departmental policies and procedures
- Liaison to plan sponsors, account teams, legal, compliance, vendors, MDs, and external constituents
- Recruit and support new talent
- Develop existing talent for growth opportunities and succession planning
- Monitor inventory and adjust staffing to ensure compliance with due dates
- Analyze reporting to identify process trends and breakdowns
Clinical Appeals Program Manager
Aetna, a CVS Health Company
05.2017 - 11.2019
- Implemented new policies and educated staff on changes
- Developed and managed the training program for clinical appeals teams
- Managed vendor oversight review process to ensure quality of SME reviews
- Reviewed and implemented legislative analysis, ensuring compliance
- Subject matter expert for clinical appeals teams, MDs and other constituents
- Maintained policies and procedures for clinical appeals teams
Supervisor, Commercial Appeals
Aetna, a CVS Health Company
10.2015 - 05.2017
- Managed day-to-day operations of UM appeals teams
- Applied strong leadership talents and problem-solving to promote team efficiency
- Conducted regular reviews of operations and identified areas for improvement
- Monitored inventory and production reports and adjusted staffing as needed to ensure turnaround times on appeals were met
- Conducted routine team meetings and 1x1 performance reviews
- Managed projects when assigned
- Participated in recruitment and hiring processes
- Maintained compliance with policies and procedures
- Monitored staff clinical development, production and quality
Clinical Team Lead, External Review
Aetna, a CVS Health Company
01.2011 - 10.2015
- Managed end-to-end clinical review for eligible external review files and 3rd party IRO requests
- Collaborated with regulators to ensure compliance with case submissions based on regulatory requirements
- External review subject matter expert for internal and external constituents
- Onboarded new hires and provided coaching and feedback as needed
Appeals Nurse Consultant
Aetna, a CVS Health Company
06.2007 - 12.2010
- Reviewed documentation and interpreted data from medical records
- Applied clinical criteria and policies in line with regulatory and accreditation requirements for member and provider appeals
- Ensured appeal case compliance and regulatory standards were met
- Panel hearing coordinator for clinical and non-clinical appeals
- Independently coordinated with MDs and other subject matter experts for resolution of appeals
Registered Nurse
Cardiology of Georgia
2002 - 2004
Registered Nurse
Northside Cardiology PC
2002 - 2004
Registered Nurse
Northwest Florida Heart Group
1998 - 2002
Licensed Practical Nurse
Northwest Florida Heart Group
1996 - 1998
Education
Master of Science - Nursing Leadership And Management
The University of Alabama
Tuscaloosa, AL2015
Bachelor of Science - Nursing
University of South Alabama
Mobile, AL2004
Associate of Science - Nursing
Pensacola State College
Pensacola, FL1998
Skills
- Healthcare management
- Clinical appeals operations
- Development of high performing teams
- Interpretation of clinical policy and regulations
Timeline
Principal Clinical Leader, Commercial Appeals Ops
Aetna, a CVS Health Company
11.2019 - Current
Clinical Appeals Program Manager
Aetna, a CVS Health Company
05.2017 - 11.2019
Supervisor, Commercial Appeals
Aetna, a CVS Health Company
10.2015 - 05.2017
Clinical Team Lead, External Review
Aetna, a CVS Health Company
01.2011 - 10.2015
Appeals Nurse Consultant
Aetna, a CVS Health Company
06.2007 - 12.2010
Registered Nurse
Cardiology of Georgia
2002 - 2004
Registered Nurse
Northside Cardiology PC
2002 - 2004
Registered Nurse
Northwest Florida Heart Group
1998 - 2002
Licensed Practical Nurse
Northwest Florida Heart Group
1996 - 1998
Master of Science - Nursing Leadership And Management
The University of Alabama
Bachelor of Science - Nursing
University of South Alabama
Associate of Science - Nursing
Pensacola State College
Similar Profiles
CHRISTINE DOLSCHRISTINE DOLS
SENIOR MANAGER, NETWORK CONTRACTING at Aetna, a CVS Health Company (First Health Network)SENIOR MANAGER, NETWORK CONTRACTING at Aetna, a CVS Health Company (First Health Network)
Adrienne HuntAdrienne Hunt
Member Services Representative at Aetna, a CVS Health CompanyMember Services Representative at Aetna, a CVS Health Company
Laurie FowlerLaurie Fowler
Customer Service Representative at Aetna, a CVS Health CompanyCustomer Service Representative at Aetna, a CVS Health Company
Brandon Michael BurkesBrandon Michael Burkes
New Business Account Executive at ZoominfoNew Business Account Executive at Zoominfo
Denitria BrownDenitria Brown
Shift Lead at WalgreensShift Lead at Walgreens