We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: This is an individual contributor role. The Senior Manager negotiates, executes, conducts high level review and analysis, dispute resolution and/or settlement negotiations of contracts. Works with larger and more complex, market/regional/national based groups/systems in accordance with company standards to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals and cost initiatives. The Senior Manager will be responsible for contracting and implementing fee for service and value-based agreements with key physician groups, facilities, and ancillary providers to support commercial and individual exchange networks. This person will also work collaboratively with Aetna and CVS departments to identify initiatives to improve physician performance and quality of care provided to our members. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities. What You’ll Do Lead end-to-end contract negotiations, execution, and analysis with a focus on hospital, ph
Provider Network Relationship Manager (Ohio)
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Role overview
Job description
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary:
This is an individual contributor role.
As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.
This position assesses overall network composition and potential provider partners in order to identify and service partnerships that will advance and differentiate the OhioRISE Network. This executes, services and may negotiate contracts with local market providers in accordance with company and program standards to enhance provider networks and exceed accessibility, quality, and financial goals and cost initiatives.
Key Responsibilities:
- Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships and partners in the development of business strategy and programs to support the operational plans.
- Collaborates cross-functionally to ensure resolution of escalated issues or projects for assigned provider systems and monitors performance and adherence to scorecards and payout schedules based on established quality, growth, and clinical measures.
- Educates internal and external parties as needed to ensure compliance with contract policies and parameters, plan design, compensation processes, technology, performance measurement techniques, policies, and procedures.
- Meets with key providers periodically to ensure service levels are meeting expectations.
- Manages the development of agendas, validates materials, and facilitates external provider meetings.
- May collaborate cross-functionally on the implementation of large provider systems, to manage cost drivers, data reports and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution.
- Drives provider engagement, and may recruit providers, as needed to ensure attainment of network expansion and adequacy targets.
- Assists with the design, development, management, and or implementation of strategic network configurations and integration activities.
- Serves as a subject matter expert (SME) for less experienced team members and internal partners.
Required Qualifications:
- 5+ years of experience in Medicaid managed care, with a strong ability to influence and a proven track record of working with individual providers and complex provider systems or groups.
- Minimum of 2 years of experience reviewing, analyzing, and auditing healthcare claims and claims data, including identifying discrepancies, researching and resolving claim issues, and providing insights to support accurate and effective claims administration.
- Demonstrated experience reviewing contracts for compliance with applicable state regulatory requirements, identifying potential compliance issues, and ensuring contractual terms align with established regulations and standards.
- Strong communication, critical thinking, problem-resolution and interpersonal skills.
- Candidates must reside in the state of Ohio.
- Ability to travel within the state as needed.
- Proficiency with MS Office Suite applications.
Preferred Qualifications:
- In depth knowledge of behavioral health market and strong experience building and maintaining relationships with behavioral health providers.
- In-depth knowledge of Ohio managed care market, with Medicaid experience preferred.
Education:
- Bachelor's degree preferred, or a combination of professional work experience and education.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$60,300.00 - $132,600.00This 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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
What they are looking for
Skills & requirements
Qualification
5+ years of experience in Medicaid managed care, with a strong ability to influence and a proven track record of working with individual providers and complex provider systems or groups; Minimum of 2 years of experience reviewing, analyzing, and auditing healthcare claims and claims data, including identifying discrepancies, researching and resolving claim issues, and providing insights to support accurate and effective claims administration
Hiring company
Cvshealth
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