Full-Time

Executive Director

Network Management

Posted on 2/28/2025

CVS Health

CVS Health

10,001+ employees

Comprehensive pharmacy and healthcare services

Compensation Overview

$131.5k - $303.2kAnnually

+ Bonus + Commission + Short-term Incentive Program + Equity Award Program

Senior, Expert

Company Historically Provides H1B Sponsorship

Remote in USA

Candidate must reside in Florida.

Category
Management Consulting
Consulting
Required Skills
Data Analysis
Requirements
  • Person must reside in Florida.
  • 10+ years of experience in managed care; leading and managing teams.
  • Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers.
  • In-depth knowledge of various reimbursement structures and payment methodologies for both hospitals and physicians.
  • Comprehensive understanding of value-based strategies and population health management, and Aetna’s related strategic initiatives.
  • Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery systems and large physician groups.
  • May require knowledge of MACRA and other government programs (ex. Bundled payments) depending on market.
  • Solid leadership skills including staff development.
  • Understands the regulatory environment and ensures contractual compliance with federal and state requirements.
  • Demonstrated a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.
Responsibilities
  • Leading and developing the overall network and provider relations strategy for given area of responsibility (ie. defined geographic area) and drives teams to execution.
  • Leading the design, development, management, and/or implementation of strategic network configurations that drive membership growth.
  • Leading and negotiating at the C-Suite level externally and internally in the payer arenas.
  • Developing, directing, and maintaining relationships with external and internal care providers and their organizations. Building and optimizing community-based partnerships.
  • Providing network strategy support to sales and marketing, along with assistance on community relations related items to achieve market and segment goals.
  • Overseeing and/or negotiating the most complex, competitive contractual relationships with providers according to prescribed guidelines in support of enterprise and local strategies.
  • Overall accountability for contract negotiations, involving all provider types including at-risk arrangements, IPA/PHO, hospital, and large provider groups.
  • Providing a solid understanding and expertise in the end- to-end aspects of provider contracting from modeling, configuration, utilization management, claims and analytics, including provider risk sharing.
  • Negotiating complex contract language and initiate legal reviews as needed; ensure all required reviews are completed by appropriate functional areas.
  • Supporting sales and retention efforts through finalist presentations and engagements with clients, prospects, brokers, and consultants.
  • Ensuring network adequacy and implementing actions to build out network expansion markets and/or to close gaps.
  • Advancing the company strategy to adopt value-based payment models; coordinates with VBC network team and/or may directly lead teams to develop, negotiate and manage complex Value Based and Accountable Care (ACO) relationships.
  • May oversee the negotiation, implementation, and management of VBC agreements.
  • Leading the Joint Operating Committee meetings for VBC arrangements.
  • Representing the organization at related external provider meetings and conferences.
  • May have responsibilities related to Joint Venture alliances.
  • Working closely with Population Health resources to enable and improve clinical outcomes.
  • Responsibility for understanding medical cost issues and medical cost ratios (MLRs) and initiating appropriate action to manage improvement initiatives and scoreable action items.
  • Reviewing analytics with medical economics and working with providers to develop collaborative initiatives that improve quality results and manage costs.
  • Driving improvement in market provider and member satisfaction results by partnering with medical management, marketing, finance, and service operations.
  • Ensuring responses to inquiries/issues generated by the provider service center, provider data services and other internal departments to address claims issues, contract interpretation, provider, and complex member issues.
  • Requiring communicating with internal/external parties by phone and/or in person; may require travel to offsite locations. Ensuring a wide variety of cross-functional Stars strategic initiatives remains on track.
  • Ensuring innovation and integration of Stars industry best practices.
  • Maintaining a pulse of external environment factors that may impact the Stars program, including CMS policy direction.
  • Driving strategic goals/plan and messaging status to CVS and Aetna C suite, including resolving barriers and engaging decisionmakers.
  • Identification of cross-enterprise initiatives necessary to achieve Stars and Member Experience objectives.
  • Responsibility for providing guidance and direction to external consultants and cross-functional team members as required in support of initiatives.
  • Stimulating strategic thinking in support of business direction.
  • Providing information, expert opinion and thought leadership needed to support the attainment of Stars and Member Experience Objective.
  • May represent the Stars organization at various forums (internal and external) or executive leadership briefings.
  • Developing communication vehicles for presentations/speeches.
  • Developing issues relative to organization's strategic direction.
  • Identifying issues, coordinating analysis and initiation of corrective action.
  • Managing special projects that impact Stars policies or strategic direction.
  • Partnering effectively within the team and across the organization to ensure strategic initiatives stay aligned to plan and elevate solutions to barriers and decisions needed to executive leaders at the highest levels of organization.
  • Supporting completion of policy/legislative analysis and response to new regulations/legislation.
  • Preparing advocacy material for a variety of audiences.
  • Supporting CVS Health in attracting, retaining, and engaging a diverse and inclusive consumer-centric workforce that delivers on our purpose and reflects the communities in which we work, live, and serve.
Desired Qualifications
  • Demonstrated experience with contracting for Commercial, Medicare, IFP and Medicaid lines of business.
  • Advanced degree in applicable field.

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access comprehensive health management solutions. The company's goal is to enhance access to quality care and support people in achieving better health.

Company Size

10,001+

Company Stage

Debt Financing

Total Funding

N/A

Headquarters

Woonsocket, Rhode Island

Founded

1963

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Simplify's Take

What believers are saying

  • Telehealth market growth offers CVS Health opportunities to expand virtual care services.
  • AI in pharmacy operations can streamline processes and improve service accuracy for CVS.
  • Health and wellness app market growth allows CVS to enhance digital health offerings.

What critics are saying

  • Closure of CVS locations may indicate downsizing, affecting customer access and revenue.
  • Smaller-footprint stores may limit product range, reducing impulse purchases and sales.
  • Digital personalization focus requires significant investment, posing financial and cybersecurity risks.

What makes CVS Health unique

  • CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.
  • The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.
  • CVS Health's digital app aims to personalize healthcare, enhancing customer experience.

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Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Company News

Lehigh Valley Live
Mar 11th, 2025
Easton CVS closing in April. What to know about your prescriptions.

CVS Pharmacy will close its 620 Old Philadelphia Road location on April 16.

PYMNTS
Mar 9th, 2025
Cvs Plans Chain Of Smaller-Footprint Pharmacy-Focused Stores

CVS is reportedly opening 12 smaller-footprint locations focused more on healthcare than consumer products. As The Wall Street Journal (WSJ) reported Sunday (March 9), the new stores will feature full-service pharmacies but limited retail. These stores, the report said, will be — on average — under 5,000 square feet, making them not even half the size of a typical CVS. The stores are expected to open this year around the U.S

The Morning Call
Mar 4th, 2025
CVS Pharmacy location to close in the Lehigh Valley

CVS Pharmacy location to close in the Lehigh Valley.

Investing.com
Mar 4th, 2025
Wellvana expands with CVS Health's Medicare business

In a strategic move, CVS Pharmacy introduced a new 3-in-1 test for Influenza A, Influenza B, and COVID-19, available at around 1,600 locations across 37 states, enhancing its testing and treatment capabilities.

PYMNTS
Feb 28th, 2025
Marqeta And Green Dot Partner To Facilitate Cash Deposits

Marqeta customers and their users can now make cash deposits at Green Dot’s network of more than 95,000 locations across the U.S. This capability comes from a new partnership between Marqeta, whose platform enables businesses to embed financial services into their branded experience, and Green Dot, whose network offers cash-in and cash-out services at Walmart, Walgreens, 7-Eleven, CVS and other retail locations, the companies said in a Friday (Feb. 28) press release. The partnership will facilitate Marqeta’s cash load offering, according to the release

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