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Position Summary

The Medicaid Network Provider Relations Manager oversees our Medicaid Provider Experience programs to oversee and maintain provider risk management and positive relationships supporting high value initiatives with our Network Providers. This role acts as the primary contact for an assigned profile of larger and more complex providers (i.e. market/ regional/ national, large group or hospital systems). Drives the implementation of internal and external solutions to achieve provider satisfaction, cost targets, network growth, and efficiency targets.

• Position will partner with external provider engagement representatives and internal provider relations representatives to ensure successful Provider relationships, network performance including clinical, and affordability targeted improvements as identified.

• Deploy the Medicaid Provider Engagement program through the local market Provider Representatives

• Partner with internal / external Network Provider Relations staff to ensure “best in class” Provider Relationships

• Assist in the recruitment of new providers as needed and maintain compliance with all network access requirements

• Recommend and deploy training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed

• Recommend Network Action Plans to ensure network compliance with any and/all state network compliance requirements

• Schedules and facilitates both onsite and virtual Provider Advisory Group and JOC meetings to work with provider management to implement changes via coordination with Quality Management to develop appropriate provider clinical measure improvements and implement those measures in the provider community

• Assist with the monitoring of executed provider contracts to ensure network access meets state requirements

• Coordinates provider information with Provider Data Services including Member Services and other internal departments as requested as provider demographics are updated

• Provides Best-In-Class service to providers by resolving problems and advising providers of new protocols, policies, and procedures

• Participates in weekly Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance; compiles data and staff metrics in order to complete regulatory deliverables; participates in all internal compliance audits and regulatory reviews

• Assists as requested for response to governmental, regulatory and quality assurance provider complaints; timely and continuous reconciliation of provider records; oversees Provider access and availability by reviewing appointment availability audits conducted by staff

• Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters

• Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with member services and other internal departments.

• Promotes and educate providers on cultural competency

Required Qualifications

• Minimum of 5+ years of experience in Provider Relations; experience in Medicaid servicing or managing non-standard relationships with providers with exposure to benefit plan design and/or contract interpretation

• Excellent interpersonal skills and the ability to work with others at all levels

• Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards

• Excellent analytical and problem-solving skills

• Strong communication and presentation skills

• Candidates are to reside within applicable state with ability to travel up to 50% to provider sites and Aetna office locations as required

Preferred Qualifications

• Preference of candidates to live in Baltimore or Anne Arundel County

Education

Bachelor’s degree or an equivalent combination of formal education and experience

Pay Range

The typical pay range for this role is:

$66,330.00 - $145,860.00

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 11/03/2024

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

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.