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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.

 

Duties:

Research and handle contract related issues (ability to research and deep dive). Claims research related to provider set up issues, payment resolutions and coordinate with Claims SMEProvider visits onsite, virtual, and telephonic Facilitate JOCs and webinars.Provider orientations/visitsProvider trainingState projectsCreate and manage provider-facing communications: newsletters, website updates, provider manual, email/fax blast.Collaborate with Quality Management and VBS team to assist with facilitation of provider request to enhance quality metrics and relationship building.Coordinate with Network Management to issue provider CAPMonitor Grievances according NCQA standards categories (3 grievances per QTR), including progressive corrective action.Monitor provider performance in accordance with provider responsibilities policy, contract, state, and federal requirements.Attend Plan committee meetings, as needed.Re-credentialing non-responder follow up.Communicate growth partner response to providers.Manage IPA provider rosters, submit to MPOS.Document visits/encounters in the appropriate systems (CRM)Travel within MarketOther duties as assigned.SKY Requirements: Must be available to meet at the location requested by the Department, DCBS, and DJJ within twenty-four (24) hours notice from the Department.

Required Qualifications

Candidates are to reside within Kentucky or within 2 hours of border with ability to travel as needed to provider sites and Aetna office locations as required.Minimum 2 years working knowledge of business segment with an understanding of KY MedicaidExcellent interpersonal skills and the ability to work with others at all levels.Excellent analytical and problem-solving skillsStrong communication and presentation skills

Preferred Qualifications

Previous MCO experience working with the Medicaid line of business.3+ years' experience in Medicaid Managed Care business segment environment with exposure to benefits and/or contract interpretation educationKnowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards

Education

Bachelor's degree preferred/specialized training/relevant professional qualification

SKY:

Must be available to meet at the location requested by the Department, DCBS, and DJJ within twenty-four (24) hours notice from the Department. Responsible for ensuring access to and availability of provider services to meet the needs of the SKY program and for educating network providers on the SKY program. Coordinate network development and all communications with network providers, out of network providers, as applicable, and subcontractors who are involved in clinical services. Responsible for supporting the resolution of provider access and availability issues. Must have knowledge of Kentucky providers including Behavioral Health providers and patterns of care/referral in Kentucky. Shall have experience of detailed knowledge of the foster care and juvenile justice systems, adoption assistance, the delivery of behavioral health services, trauma informed care, ACEs, crisis intervention services, and evidence based practices applicable to the SKY population.

Pay Range

The typical pay range for this role is:

$54,300.00 - $119,340.00

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

We anticipate the application window for this opening will close on: 11/13/2024

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