Provider Relations Senior Manager, Medicaid-Must reside in IL

Provider Experience Manager

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. Provides strategic leadership and oversight for the provider experience staff (approximately 3-4 colleagues). Develop long-term relationships with network providers and IL Associations by enhancing interactions between providers and the health plan, ensuring seamless communication, operational efficiency, and overall enhancing the provider experience. Drives the implementation of internal and external solutions to achieve provider satisfaction, cost targets, utilization / performance, network growth, and efficiency targets. Manages and oversees compliance within our network responsibilities as provided within the state Medicaid contractual requirements. This position holds a variety of functions for provider experience to ensure successful provider relationship, network performance including clinical, and affordability targeted improvements as identified and overall staffing support.

Duties :

• Provider Engagement & Relationship Management : Strengthen partnerships with network providers to improve their experience and satisfaction. Develop and maintain strong relationships with Tier one and Tier Two providers, along with other specialties such as HCBS, LTC, BH, DMEs, and others to support staff.
• Process Improvement : Work with Sr. Managers and Director to develop and implement strategies to streamline, policies, procedures, provider interactions / trainings and optimize workflows.
• Data & Insights Utilization : Leverage analytics to identify trends, address escalated provider concerns, and enhance service delivery. Assist PE staff to educate providers on Availity usage and reports. Develop JOCs with our priority providers to educate performance status, along with working with cross-functional teams for additional support.
• Cross Functional Team Collaboration : Work closely with internal teams to align provider experience initiatives with organizational goals. Assist and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Revalidation, Grievance and Appeals, SIU, etc. Coordinate provider status information with Member / Provider Services and other internal departments.
• Stakeholder Collaboration : Participate in HFS, IAMHP, and IL Associations Meetings / Conferences.
• Training & Support : Ensure providers have access to necessary resources, training, and support for compliance and operational success. Develop and implement training programs and educational materials for providers as well as for internal staff that aligns PE / Network functions with Operations and Claims as needed
• Research, review, and prepare responses for all governmental, regulatory and quality assurance provider complaints, timely and continuous reconciliation of provider records.
• Provides support and maintenance assistance for websites, portals, directories, provider manuals, and dashboards. Plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications, and Fax Blasts.
• Issue Resolution : Address provider challenges proactively and implement solutions to improve their experience. Monitor day to day provider complaint and work with PE Staff and other internal partners to resolve timely or by due date set by Compliance. Also, work to resolve provider concerns related to referrals, eligibility, revalidation, and policy matters.
• Compliance : Ensure providers adhere to regulatory requirements and network policies. Review departmental policies and submit for approval. Assist Director with State / NCQA Audits gathering details for submissions. Conducts regular work area audits in order to consistently monitor and measure teamwork compliance, providing guidance on regulatory changes, protocols, and standards.
• Strategic Oversight : Lead initiatives to improve provider satisfaction and streamline operations. Oversees staff responsible for initial and ongoing provider in-services and provider education; monitor and review provider satisfaction surveys results conducted by vendor. Review results with cross-functional teams and develop action plan on how to improve scores. Oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by vendor and NCQA requirements.
• Team Leadership : Manage provider relations staff and oversee day-to-day operations. Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions. Monitors staff performance, including monthly staff metrics; coaches and mentors' staff on performance issues or concerns.

Required Qualifications :

Education : Bachelor's degree preferred / specialized training / relevant professional qualifications

Pay Range : The typical pay range for this role is : $82,940.00 - $182,549.00

Great benefits for great people : We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include :

We anticipate the application window for this opening will close on : 12 / 01 / 2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.