Network Audit Program Manager

CVS Health

6d

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary Serves as a key member of the Network Audit team, leveraging deep expertise in healthcare provider contracts, provider data management, network operations, and data auditing. Supports the development and maintenance of a market-specific provider network that meets or exceeds targets for accessibility, regulatory compliance, quality, and financial performance. Oversees and evaluates the accuracy and timeliness of provider network application processing to drive strategic growth initiatives. Tracks and documents quality and productivity metrics, providing actionable insights and performance data to support management decisions and training program development. Collaborates cross-functionally to support the negotiation and renewal of provider agreements. Offers expert guidance on provider application requirements, conducts audits to ensure data integrity, and initiates or supports remediation efforts as needed to maintain high standards of operational excellence.

Requirements

• 3-5 years of experience working in managed healthcare contracting, network management, or supporting roles.
• 1-2 years project management experience
• SharePoint experience (Manage and build out)
• Medicaid experience
• QuickBase, Excel (Pivot tables, Basic formulas) experience
• Bachelor' Degree or equivalent work experience (HS diploma + 4 years relevant experience)

Nice To Haves

• 3-5 years of experience with collaboration and cross-functional teamwork
• 3-5 years of experience with multi-tasking and prioritizing duties
• 3-5 years of experience with complex problem-solving and decision-making skills

Responsibilities

• Support the development and execution of results-driven programs and innovative initiatives within the network audit area, operating under general supervision.
• Coordinates and supports the network contracting lifecycle including but not limited to intake and evaluation of provider network applications, agreement execution, and enablement of provider credentialing and load for claims processing.
• Employ strategic thinking in departmental initiatives by aligning projects with organizational objectives, contributing to strategy development, and utilizing data analysis to support informed decision-making.
• Demonstrate the ability to address complex challenges, create innovative solutions, and approach existing issues from new perspectives.
• Identifies trends impacting service delivery and works collaboratively with appropriate parties to recommend enhancements or solutions that address potential challenges, including improving management controls, tightening procedures, or fulfilling training needs.
• Utilizes recruitment and audit applications and contract management systems to audit complex provider network applications which may include agreements, amendments, and fee schedules for individuals and groups wanting to participate in Aetna’s provider network.
• Performs audits to verify compliance ensure adherence to performance standards, ensuring superior outcomes in quality, accuracy, and timeliness.
• Offers technical expertise and subject matter knowledge regarding policies, procedures, and network audit applications and system tools.
• Prepares and presents project progress updates, emphasizing accomplishments, risks, and mitigation measures. Demonstrating strong communication and presentation skills to effectively convey information to varied audiences.
• Cultivates relationships with internal teams and external clients to enhance departmental results.
• Promotes a culture of trust by promptly identifying risks and dependencies, enabling timely mitigation or strategic responses.
• Offers continuous feedback and serves as a subject matter expert in resolving procedural challenges.
• Mentor audit staff on work procedures, ensuring compliance with established audit processes and maintaining high-quality standards.
• Delivers training to network audit personnel.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees