Provider Relations Senior Manager, Medicaid-Must reside in IL

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Position Summary

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

• MUST RESIDE IN ILLINOIS and commutable distance to Chicago and surrounding suburbs with ability to travel as needed to provider sites and Aetna office locations as required
• Excellent interpersonal skills and the ability to work with others at all levels
• Minimum of 5+ years’ working experience in Provider Relations or Network Strategy
• Minimum 5+ years' experience in Medicaid Managed Care business segment environment with exposure to benefits and / or contract interpretation
• Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and / or Network Performance Standards
• Progressive leadership experience
• Excellent analytical and problem-solving skills
• Strong communication and presentation skills
• Adept at execution and delivery (planning, delivering and supporting)
• Adept at collaboration
• Working knowledge of business segment specific codes, products, and terminology

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

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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.

For more information, visit

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.