CVS Health

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

MUST RESIDE IN MIAMI DADE COUNTY

Position Summary:

Optimizes interaction with assigned providers and internal business partners to establish and maintain productive, professional relationships. Monitors service capabilities and collaborates cross-functionally to ensure that the needs of the 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, and contract coordination. Performs credentialing support activities as needed. Educates providers to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures. Meets with key providers to ensure service levels are meeting expectations. Manages the development of agenda, validates materials, and facilitates external provider meetings and JOCs. May collaborate cross-functionally on the implementation of large provider systems, to manage cross drivers and execute specific cost initiatives to support business objective and to identify trends and enlist assistance in problem resolution.

Responsibilities:

• Research and handle contract related issues (ability to research and deep dive).
• Claims research related to provider set up issues, payment resolutions and coordinate with Claims SME
• Provider visits onsite, virtual, and telephonic
• Facilitate JOCs and webinars
• Provider orientations/visits
• Provider training
• State projects
• Create and manage provider-facing communications: newsletters, website updates, provider manual, email/fax blast
• Collaborates w/ Quality Management and VBS team to assist w/ facilitation of provider request to enhance quality metrics and relationship building
• Coordinate with Network Management to issue provider CAP
• Monitor Grievances according NCQA standards categories (3 grievances per QTR), including progressive corrective action
• Monitor provider performance in accordance with provider responsibilities policy, contract, state and federal requirements
• Attend Plan committee meetings, as needed
• Recredentialing non-responder follow up
• Communicate growth partner response to providers
• Manage IPA provider rosters, submit to MPOS
• Document visits/encounters in the appropriate systems (CRM)
• Travel within Market
• Other duties as assigned

Job Requirements:

• 3 year's experience in business segment environment servicing providers with exposure to benefits and/or contract interpretation.
• 3-5 year's experience with business segment specific policy, benefits plan design and language.
• Strong verbal and written communication, interpersonal problem resolution and critical thinking skills.
• Working knowledge of business segment specific codes, products and terminology.
• Bilingual (English and Spanish) preferred.

Education:

Bachelor's degree or an equivalent combination of formal education and experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,300.00 - $119,340.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/31/2025

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