Medicaid Network Provider Relations 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.Position Summary

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 (i.e., market/ regional/ national, large group or hospital systems). Drives the implementation of internal and external solutions to achieve provider satisfaction, cost targets, network growth, and efficiency targets.Duties:

• 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.

Required Qualifications

• 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

Preferred Qualifications

• 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 businessEducation

Bachelor's degree preferred/specialized training/relevant professional qualification Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$66,330.00 - $145,860.00This 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.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 peopleWe 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 https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 09/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Client-provided location(s): Springfield, IL

Job ID: CVS-R0629859

Employment Type: OTHER

Posted: 2025-08-24T19:39:53