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Position Summary
Business Overview:

At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of Texas members. We value diversity and are dedicated to helping you achieve your career goals.

Position Summary:

The Medicaid Network State Director manages and oversees compliance with our Network responsibilities as provided within the State Medicaid contractual requirements as outlined below:
• This Position will manage separate 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 State Network Director will manage and deploy the Medicaid National Provider Engagement Program through the Local Market Network Engagement Provider Representatives within their respective Leadership.
• The State Network Director will manage and direct the internal Network Provider Relations staff to ensure “best in class” Provider Relationships.
• The State Network Director will coordinate and assist in the recruitment of new providers as needed and maintain compliance with all network access requirements.
• Assist and develop Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirements.
• Manages Local Provider Engagement Team to Deploy National Engagement Model including using Company offices when required or requested by Senior Network Leaders.
• Manages Local Provider Relations staff to ensure Market Leading Provider Satisfaction.
• Facilitates and attends, as needed including Traveling externally when required for Provider Advisory Group and JOC meetings to work with management to implement changes via coordination Quality Management to develop appropriate provider Clinical measure improvements and implement those measures in the provider community.
• Coordinate’s provider information with member services and other internal departments as requested.
• Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.
• Develops training materials for staff and provider network; oversees staff responsible for initial and ongoing provider in-services and provider education; develops and implements provider satisfaction surveys including attending Company functions that may require travel as necessary.
• Participates in weekly Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance; complies data and staff metrics to complete regulatory deliverables; participates in all internal compliance audits and Regulatory reviews.
• Research, review, and prepare responses for all governmental, regulatory, and quality assurance provider complaints; timely and continuous reconciliation of provider records; oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by staff.
• Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications, and Fax Blasts.
• 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.
• Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions. Monitors staff performance, including weekly staff metrics; coaches and mentors’ staff on performance issues or concerns.
• Promotes and educate providers on cultural competency.

Required Qualifications
• Candidates must reside within Texas.
• Minimum of 5 to 7 years recent managed care Network experience in Provider Relations
• Minimum of 3 years management experience, including supervising high-performance teams; developing and coaching employees
• 3-5 years Medicaid Network experience
• 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.
• 3+ years’ experience with personal computers, keyboard navigation and MS Office Suite applications.
• Ability to travel to meet business needs.

Preferred Qualifications
• Excellent interpersonal skills and the ability to work with others at all levels of the organization

Education

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

Pay Range

The typical pay range for this role is:

$100,000.00 - $231,500.00

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: 11/29/2024

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