Lead Director, Network Management, Provider Engagement

Lead Director, Provider Engagement

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. Candidate must reside in Texas Position Summary The Lead Director, Provider Engagement manages and oversees compliance with our Provider Engagement responsibilities as provided within the State Medicaid contractual requirements. This role is responsible for managing distinct functions that support both internal and external Provider Engagement representatives. The position ensures the development and maintenance of successful Provider relationships, drives Network Performance, and supports strategic Growth Partner initiatives as appropriate. Manage and deploy the Medicaid National Provider Engagement Program through the Local Market. Manage and direct the internal / external Provider Engagement staff to ensure "best in class" Provider Relationships. Implement and / or deliver training programs and educational materials for Providers. Ensure internal staff participates in applicable training and aligns Provider Engagement functions with Operations and Claims as needed. Assist and develop action plans to ensure Provider Engagement is compliant with all State requirements. Role and Responsibilities Responsible for updating and monitoring performance of KPI / Goals to include but not limited to CRM. Manages Local Provider Engagement Team to Deploy National Engagement Model. Responsible for maintaining local policies and procedures. Manages Local Provider Relations staff to ensure Market Leading Provider Satisfaction. Collaborate with the Operations Department for claims triage, escalations where applicable, and Provider education. Facilitate and / or Chair Provider Advisory Group and JOC meetings. Oversees the monitoring of State and Federal requirements, reporting, and audits. Provides oversight for Provider Escalations at the Health Plan and State level. Oversees staff responsible for initial and ongoing provider education. Responsible for required Provider Satisfaction end-to-end process and Stakeholder partnership to ensure alignment with Market established SOW. Compiles data and staff metrics to complete regulatory deliverables; participates in all internal compliance audits and Regulatory reviews. Ensures accurate and ongoing reconciliation of provider records to maintain data integrity. Oversees provider Access and Availability by reviewing audits conducted by third party vendor and / or staff; and monitoring performance trends. Ensures all related documentation is accurately recorded and maintained in the designated repository for compliance and audit readiness. Oversight of Provider website, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications and email / fax blasts in collaboration with Provider Enablement & Strategy. Collaborate with Provider Enablement & Strategy on Provider-facing communications, desktops, workflows, external trainings, reporting, and HUB support. Recruits, develops, and supports staff. Manages key personnel actions such as hiring, terminations, performance, salary reviews, and disciplinary actions. Tracks performance through weekly metrics, holds regular one-on-one meetings, and provides coaching and mentoring as needed. Incorporate and demonstrate Heart at Work Behaviors on a consistent basis. Promotes and educates providers on Cultural Competency and Critical Incidents. Required Qualifications Minimum of 5 to 7 years of recent Managed Care experience in Network / Provider Engagement Employee Supervision with 3-5 Years in Medicaid Network / Provider Engagement. Travel within the state as needed. Excellent interpersonal skills and the ability to work with others at all levels. Candidate must reside in Texas Preferred Qualifications Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Lifecycle, Provider Appeals & Disputes, and Network Performance Standards. Experience in Medical Terminology, CPT, ICD-10 codes, etc. Excellent analytical and problem-solving skills. Strong communication, negotiation, and presentation skills. Education Bachelor's degree preferred or a combination of professional work experience and education. Pay Range The typical pay range for this role is : $100,000.00 - $231,540.00 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 : 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. We anticipate the application window for this opening will close on : 10 / 31 / 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.