Sr Mgr, Network Mgt - Medicaid VBC KY/WV (IC)

at  CVS Health

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POSITION SUMMARY

The Sr. Manager Medicaid VBC KY/WV manages and oversees compliance with our Network responsibilities as provided within the State Medicaid contractual requirements as outlined below:

• Accountable for working with our strategic provider partners to develop innovative value-based solutions to meet total cost and quality goals for our Medicaid businesses.
• Responsible for designing conceptual models, initiative planning, and negotiating high value/risk contracts with the most complex and challenging, market/region/national, largest group/system or highest value/volume of spend providers in accordance with company standards in order to maintain and enhance provider networks, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives.
• Works with Quality Team, Health Plan Leadership team, VBS reporting team and other staff to manage contract performance and drives the development and implementation of value based contract relationships in support of business strategies.
• Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve value based contracting targets and manage medical costs through effective value based contracting to meet state contract(s) and product requirements.
• This Position will manage combined functions for external provider engagement representatives and internal provider relations representatives to ensure successful Provider Relationships, Network Performance including Clinical and Affordability Targeted Improvements as identified.
• The Sr. Manager will assist in the recruitment of new value based providers as needed and maintain compliance with all state value based requirements.
• Recommend training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed.
• Recommend Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirements

Role/responsibilities

• Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners.
• Works with health plan staff to create a value based strategic plan with targeted provider groups to ensure we meet state guidelines for value based provider agreements
• Continuous review of value based provider performance and movement of providers along the value based continuum as they are ready.
• In charge of complete value based contracting cycle from planning, gaining approvals, creating documents, and negotiation to oversee loading of executed arrangements.
• Facilitates and attends, as needed, including Traveling externally when required for, Provider meetings and negotiations.
• Oversees the monitoring and loading of executed value based provider contracts to ensure State requirements.
• Coordinate’s provider information with member services and other internal departments as requested.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements.
• Collaborates with internal partners to assess effectiveness of tactical plan in managing costs. May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met.
• Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with member services and other internal departments.

This is an individual contributor role.

REQUIRED QUALIFICATIONS

• Minimum of 3 to 4 years recent Managed Care Network Value Based Contracting experience with 2-3 years Medicaid Network experience
• Must have Microsoft Office experience with intermediate to advanced Teams, Word, Excel and PowerPoint skills
• Excellent interpersonal skills and the ability to work with others at all levels
• Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards
• Excellent analytical and problem-solving skills
• Strong communication, negotiation, and presentation skills
• Proven ability to work in a matrixed organization
• This is a work at home position, with preference given to applicants who live in Kentucky or West Virginia

PREFERRED QUALIFICATIONS

Minimum of 3 to 4 years recent Managed Care Network Value Based Contacting experience with 2-3 years Medicaid Network experience
Candidates are to reside within applicable State of Kentucky or West Virginia and may be asked to travel within the state on a periodic basis.

EDUCATION

Bachelor’s degree in a closely-related field or an equivalent combination of formal education and recent, related experience.

The Sr. Manager Medicaid VBC KY/WV manages and oversees compliance with our Network responsibilities as provided within the State Medicaid contractual requirements as outlined below:

• Accountable for working with our strategic provider partners to develop innovative value-based solutions to meet total cost and quality goals for our Medicaid businesses.
• Responsible for designing conceptual models, initiative planning, and negotiating high value/risk contracts with the most complex and challenging, market/region/national, largest group/system or highest value/volume of spend providers in accordance with company standards in order to maintain and enhance provider networks, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives.
• Works with Quality Team, Health Plan Leadership team, VBS reporting team and other staff to manage contract performance and drives the development and implementation of value based contract relationships in support of business strategies.
• Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve value based contracting targets and manage medical costs through effective value based contracting to meet state contract(s) and product requirements.
• This Position will manage combined functions for external provider engagement representatives and internal provider relations representatives to ensure successful Provider Relationships, Network Performance including Clinical and Affordability Targeted Improvements as identified.
• The Sr. Manager will assist in the recruitment of new value based providers as needed and maintain compliance with all state value based requirements.
• Recommend training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed.
• Recommend Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirement

Role/responsibilities

• Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners.
• Works with health plan staff to create a value based strategic plan with targeted provider groups to ensure we meet state guidelines for value based provider agreements
• Continuous review of value based provider performance and movement of providers along the value based continuum as they are ready.
• In charge of complete value based contracting cycle from planning, gaining approvals, creating documents, and negotiation to oversee loading of executed arrangements.
• Facilitates and attends, as needed, including Traveling externally when required for, Provider meetings and negotiations.
• Oversees the monitoring and loading of executed value based provider contracts to ensure State requirements.
• Coordinate’s provider information with member services and other internal departments as requested.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements.
• Collaborates with internal partners to assess effectiveness of tactical plan in managing costs. May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met.
• Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with member services and other internal departments