Manager, Provider Relations

About the role

Acts as the primary resource for an internal team who respond to inquiries via a mailbox regarding Medicaid policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs. Monitors service capabilities and collaborates cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved.

Supports or assists with operational activities that may include, but are not limited to, database management, contract coordination, TIN Mapping/Certification, and credentialing support activities as needed. Collaborates cross-functionally with the implementation of large provider systems to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution. May provide guidance and training to less experienced team members.

Collaborates with Provider Enablement & Strategy on Provider-facing communications, desktops, workflows, external trainings, reporting needs, and HUB support. Ensures all turnaround times are met according to the state contractual agreement with Aetna Better Health of Oklahoma.

Other duties as assigned.

Responsibilities

• Serve as the primary resource for internal teams handling Medicaid policy and procedure inquiries.
• Monitor service capabilities and resolve escalated issues related to claims payment, contract interpretation, and provider information accuracy.
• Support operational activities including database management, contract coordination, TIN Mapping/Certification, and credentialing.
• Collaborate cross-functionally to manage cost drivers and execute cost initiatives.
• Provide guidance and training to less experienced team members.
• Collaborate with Provider Enablement & Strategy on provider-facing communications, workflows, trainings, and reporting.
• Ensure compliance with state contractual turnaround times for Aetna Better Health of Oklahoma.

Requirements

• 5+ years' work experience in a leadership role.
• Experience working in a Medicaid plan.
• Knowledge of QNXT, Quickbase, and WFM (Workflow Manager tool).
• Strong knowledge of mapping and certification of providers.
• Must reside in Oklahoma.

Qualifications

• Bachelor's degree or equivalent experience.
• Strong verbal and written communication, interpersonal, problem resolution, and critical thinking skills.

Preferred Qualifications

• Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claim Lifecycle, Provider Appeals & Disputes, and Network Performance Standards.
• Experience in Medical Terminology, CPT, ICD-10 codes, etc.

Pay

The typical pay range for this role is $54,300.00 - $119,340.00 annually. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.

Schedule

• Full time.
• 40 anticipated weekly hours.

Benefits

This full-time position is eligible for a comprehensive benefits package including:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.