Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

The Lead Director, Medicaid Provider Experience Standardization is responsible for ensuring the variations that currently exist across multiple Medicaid Health plans specific to provider contracting, credentialing, provider onboarding, loading and maintenance are standardized and documented, with strong data entry control points to drive alignment and transparency with the Network Operations Team and the Medicaid Health Plans.  This leader will execute on the Medicaid Process Standardization strategy by developing and defining the standard workflows to use for new market implementations and expansions, as well as define the process to transition each Health Plan from current state to the new standard.

This position will require continuous collaboration and consultation with complex, cross-functional stakeholder management, to ensure the desired business outcome is defined and achieved.

The ideal candidate is an initiative-taker, detail-oriented, highly organized and must exhibit strong communication and process improvement skills, with a deep understanding of Medicaid network, credentialing and provider data processes.

Key Responsibilities

Leading the execution of process mapping, workflows, audit and controls for core Network processes such as Intake, Credentialing, Provider Data Loading, Rosters, Non-Par Loads, Provider Terminations, Market Expansions and Implementations, and Deeming, including but not limited to the following:

• Design a uniformed review and control process for provider data loads and update requests / submission to ensure strong data entry control points and help drive alignment with the Network Operations Team and the Health Plans

• Enhance the bulk load process to load and update provider data within QNXT, streamlining the process to complete the spreadsheet inputs efficiently

• Implement a PRMS mailbox specific for Value Based Care providers to ensure requests are resolved appropriately by Analysts that are familiar with VBC requirements

• Advance a PRMS dashboard in which Health Plans have access to so they can track the progress / status of their requests and requests submitted by providers

• Develop a formal process and capacity to conduct periodic provider outreach to ensure accuracy of provider data and directories.

• Develop a formal process to conduct PCR audits and ProData audits to identify trends and determine opportunities for training / education

• Develop a formal process for member reassignments or member / provider communication when members’ PCPs are terminated

• Review active prior authorizations and inform the UM/CM departments prior to the completion of the termination to ensure continuity of care

• Leverage the Provider Assessment Report to proactively identify and address provider data issues

• Create and run controls such as SQL queries and analytics at regular intervals to proactively identify and address provider data issues

• Recommend prioritization of technology investment pipeline to support migration to standard workflows

• Define plan to align capabilities and processes across lines of business

Required Experience:

• 10+ years managed care / network / health insurance industry experience, specifically in Medicaid and Duals.

• Demonstrated experience successfully driving change in complex organizations.

• Demonstrated relationship management skills at the senior level; capacity to quickly build and maintain credible relationships at varying levels of the organization simultaneously.

• Experience with enterprise-wide and/or cross-functional large-scale initiatives with high degree of complexity.

• Demonstrated leadership with relevant initiatives: Business process, enterprise business project management/consulting, and/or strategic planning.

• Strong quantitative skills with ability to structure, analyze, and interpret data to identify trends and draw logical conclusions; propensity toward supporting hypothesis with strong quantitative and qualitative evidence.

• Comfort with ambiguity, ability to create a process where one doesn’t exist and deliver results

Preferred Experience:

• QXNT experience.

• Six Sigma trained or certified.

Education:

• Bachelor’s degree or equivalent professional work experience.

Pay Range

The typical pay range for this role is:

$100,000.00 - $231,540.00

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. 
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/14/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.