Provider Relations Representative (Kentucky)

CVS Health•Henderson, KY

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. This is an individual contributor role. Position Summary: Acts as the primary resource for assigned, high profile providers and/or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding Medicaid policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs. Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships. Monitors service capabilities and collaborate cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved. Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination. Performs credentialing support activities as needed. Educates Medicaid providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures. Meets with key Providers at regular intervals to ensure service levels meet expectations. Manages the development of agenda, validates materials, and facilitates external provider meetings. Collaborate cross-functionally with the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution. May provide guidance and training to less experienced team members. Strong verbal and written communication, interpersonal, problem resolution and critical thinking skills. Collaborate with Provider Enablement & Strategy on Provider-facing communications, desktops, workflows, external trainings, reporting needs, and HUB support. Other duties as assigned.

Requirements

A minimum of 5 years' work experience in healthcare.
Minimum of 3 years' experience in Medicaid Managed Care business segment environment servicing providers with exposure to benefits and/or contract interpretation.
Working knowledge of business segment specific codes, products, and terminology.
Travel within the defined territory up to 50-80% of the time.
This position must reside in KY (within 3 hours from the capital).

Nice To Haves

Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claim Lifecycle, Provider Appeals & Disputes, and Network Performance Standards.
Experience in Medical Terminology, CPT, ICD-10 codes, etc.

Responsibilities

Acts as the primary resource for assigned, high profile providers and/or groups to establish, oversee, and maintain positive relationships.
Assists with or responds to complex issues regarding Medicaid policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.
Monitors service capabilities and collaborate cross-functionally to ensure that the needs of constituents are met.
Resolves escalated issues related to claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information.
Supports or assists with operational activities such as database management and contract coordination.
Performs credentialing support activities as needed.
Educates Medicaid providers on compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures.
Meets with key Providers at regular intervals to ensure service levels meet expectations.
Manages the development of agenda, validates materials, and facilitates external provider meetings.
Collaborates cross-functionally with the implementation of large provider systems to manage cost drivers and execute specific cost initiatives.
Identifies trends and enlists assistance in problem resolution.
May provide guidance and training to less experienced team members.
Collaborates with Provider Enablement & Strategy on Provider-facing communications, desktops, workflows, external trainings, reporting needs, and HUB support.