[Work From Home] Medicaid Network Provider Relations Manager
Work with a team of bright and motivated people as a Medicaid Network Provider Relations Manager - Maryland! This role is 100% remote, giving you full control over your work environment. This position requires a strong and diverse skillset in relevant areas to drive success. The salary for this position is set at a competitive salary.
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Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important... as what we deliver.
Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
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.
Role Responsibilities
 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 presentati
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Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important... as what we deliver.
Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
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.
Role Responsibilities
 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 presentati