• 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 SME
• Provider visits onsite, virtual, and telephonic
• Facilitate JOCs and webinars.
• Provider orientations/visits
• Provider training
• State projects
• Create 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 CAP
• Monitor 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.
• Recredentialing 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 Louisville Kentucky Market
• Other duties as assigned.

Required Qualifications

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

• Minimum of 2 years' experience with 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

• 3+ years' experience in Medicaid Managed Care business segment environment with exposure to benefits and/or contract interpretation
• Working knowledge of business segment specific codes, products, and terminology

• Must work at corporate office at 9900 Corporate Campus Drive Louisville, KY 3 days a week (Tues-Thursday) if located within a 30 mile radius Preferred Qualifications

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

• Previous MCO experience working with the Medicaid line of businessEducation
Bachelor's degree preferred/specialized training/relevant professional qualificationPay Range

The typical pay range for this role is:$54,300.00 - $119,340.00This 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.

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 HealthWe anticipate the application window for this opening will close on: 02/17/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.