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.

• 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

• Minimum of 3 to 5 years' 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 in Pennsylvania with ability to travel up to 50% to provider sites and Aetna office locations as required.

• Bachelor's degree or equivalent professional work experience.