Medicaid Network Provider Relations Manager, CVS Health

CVS Health

Location:
United States, Springfield

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

66330.00 - 145860.00 USD / Year

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Job Description:

The Medicaid Network Provider Relations Manager oversees our Medicaid Provider Experience programs to oversee and maintain provider risk management and positive relationships supporting high-value initiatives with our Network Providers. This role acts as the primary contact for an assigned profile of larger and more complex providers, driving the implementation of solutions to achieve provider satisfaction, cost targets, network growth, and efficiency targets.

Job Responsibility:

Research and handle contract related issues (ability to research and deep dive)
Claims research related to provider set up issues, payment resolutions and coordinate with Claims SME
Provider visits onsite, virtual, and telephonic
Facilitate JOCs and webinars
Provider orientations/visits
Provider training
State projects
Create and manage provider-facing communications: newsletters, website updates, provider manual, email/fax blast
Collaborate with Quality Management and VBS team to assist with facilitation of provider request to enhance quality metrics and relationship building
Coordinate with Network Management to issue provider CAP
Monitor Grievances according NCQA standards categories (3 grievances per QTR), including progressive corrective action
Monitor provider performance in accordance with provider responsibilities policy, contract, state, and federal requirements
Attend Plan committee meetings, as needed
Revalidation non-responder follow up
Communicate growth partner response to providers
Manage IPA provider rosters, submit to MPOS
Document visits/encounters in the appropriate systems (CRM)
Travel within Illinois Market - approximately 20%
Other duties as assigned

Requirements:

MUST RESIDE IN ILLINOIS
Excellent interpersonal skills and the ability to work with others at all levels
Minimum of 2 years’ experience with Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards
Excellent analytical and problem-solving skills
Strong communication and presentation skills
3+ years' experience in Medicaid Managed Care business segment environment with exposure to benefits and/or contract interpretation
Working knowledge of business segment specific codes, products, and terminology

Nice to have:

Candidates are to reside within applicable state with ability to travel as needed to provider sites and Aetna office locations as required
Previous MCO experience working with the Medicaid line of business

What we offer:

Affordable medical plan options
a 401(k) plan (including matching company contributions)
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

Additional Information:

Job Posted:
August 27, 2025

Expiration:
September 30, 2025

Employment Type:

Fulltime

Work Type:

On-site work

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Medicaid Network Provider Relations Manager