Senior Analyst, Provider Relations (Metro)

CVS Health•New York, NY

4d•$50,188 - $122,400•Remote

About The Position

Responsible for managing complex provider-facing workflows, inquiries, and escalations across claims, enrollment, contracting, and regulatory functions. This role serves as a key liaison between providers (including physicians and allied healthcare professionals) and internal operations, leveraging strong analytical capabilities to investigate issues, drive resolution, and ensure compliance with regulatory and network requirements. Position is primarily remote with willingness to travel to office as needed.

Requirements

2-5 years of professional work experience
1 year in the healthcare industry
Experience with medical terminology
Experience working with Microsoft Office Suite
Ability to travel in the Metro NY Territory as needed
Proven ability to manage multiple workflows, prioritize effectively, and meet deadlines
Strong written and verbal communication skills, with the ability to convey complex information clearly

Nice To Haves

Demonstrated experience working with physicians and other healthcare providers
Strong analytical and problem-solving skills with the ability to interpret complex data and resolve issues
Triage member and provider issues (e.g., COB, eligibility, plan setup, pending claims) to appropriate teams to ensure timely resolution
Build and maintain strong, professional relationships with internal stakeholders and external provider partners
Perform root cause analysis on recurring provider issues, identifying opportunities for process improvement and policy alignment
Collaborate cross-functionally to resolve escalated issues impacting providers or operational workflows
Ensure adherence to contract terms, payment policies, and regulatory requirements
Engage directly with key providers as needed to support service levels and address concerns

Responsibilities

Manage complex provider inquiries, escalations, and operational requests across claims, enrollment, and regulatory domains
Conduct detailed research and analysis of provider disputes, including claims and policy-related issues
Investigate and respond to executive-level, Department of Insurance (DOI), and medical society complaints
Research and resolve member or plan sponsor disputes escalated by Sales or Account Management teams
Facilitate provider termination appeals and incorrect participation corrections
Coordinate provider contract adjustment requests in partnership with contracting teams
Support provider enrollment and demographic updates (e.g., TIN changes, address updates, effective dates)
Escalate and track credentialing and recredentialing issues, including non-responder follow-up
Facilitate HIPAA-related updates and compliance-related provider requests
Provide and interpret complete provider participation rosters for large provider groups
Conduct network directory validation and maintenance activities
Identify and support resolution of network deficiency gaps, including provider recruitment support
Assist with fraud, waste, and abuse (FWA) investigations
Support Medicare eligibility audits, network audits (including Metro NY), and sponsor audit requests
Participate in quarterly network filing activities and regulatory submissions
Support chart collection, HEDIS, and Risk Adjustment validation initiatives
Assist root cause analysis efforts, including roster accuracy and SAI-related clean-up
Analyze operational data trends to identify process improvement opportunities and recurring issues
Deliver targeted outreach and follow-up to improve provider compliance and data accuracy
Educate providers on administrative processes and self-service tools to improve efficiency and accuracy