Provider Network Relationship Manager (Ohio)

CVS Health•Youngstown, OH

1d•Remote

About The Position

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.

Requirements

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.

Nice To Haves

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.

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, contract 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.