Job Description
The Michigan 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 / external Network Provider Relations staff to ensure “best in class” Provider Relationships
• The State Network Director will assist in the recruitment of new providers as needed and maintain compliance with all network access requirements.
• Develops and implements training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed.
• Assist and develop Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirements
Role/responsibilities
• Manages Local Provider Engagement Team to Deploy National Engagement Model
• Manages Local Provider Relations staff to ensure Market Leading Provider Satisfaction
• Provides direction to operations teams regarding policy and procedures related to claims/providers.
• Facilitates Provider Advisory Group and JOC meetings to work with management to implement changes via coordination with Quality Management to develop appropriate provider Clinical measure improvements and implement those measures in the provider community.
• Oversees the monitoring of executed provider contracts to ensure Network Access meets State requirements.
• 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.
• Participates in Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance;
• Compiles data and staff metrics in order to complete regulatory deliverables; participates in all internal compliance audits and Regulatory reviews.
• Researches, reviews, and prepares response 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 educates providers on cultural competency
Pay Range
The typical pay range for this role is:
Minimum: 100,000
Maximum: 221,000
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
• Minimum of 5 to 7 years recent Managed Care Network experience in Provider Relations & Employee Supervision with 3-5 Years Medicaid Network
• 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
• Knowledge of Michigan Medicaid.
Preferred Qualifications
Master’s degree preferred.
Candidates to reside in applicable State or surrounding State.
Education
• Bachelor’s degree in a closely-related field or an equivalent combination of formal education and recent, related experience.
Business Overview
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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.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.