Manager, Provider Relations – National Health Systems

This is a fully remote position, open to applicants in Alabama, +42 more states.

📋 Description

• Oversee relationships with designated strategic providers

• Act as the main point of contact for provider operational challenges, inquiries, and escalations

• Investigate and address complex provider issues related to claims, rework, appeals, provider data, credentialing, and reimbursement

• Collaborate with Claims, Appeals, Operations, Provider Data, Credentialing, Medical Management, and Contracting teams

• Analyze trends in provider service, operational performance, and root causes of issues

• Support initiatives aimed at enhancing provider performance in areas such as quality, access, operational efficiency, and member experience

• Educate providers regarding health plan programs, administrative processes, self-service tools, and operational requirements

• Facilitate value-based care initiatives by engaging and educating providers, along with providing operational support

• Assist in network adequacy efforts, provider recruitment, and regulatory initiatives

• Research and address provider complaints, disputes, executive escalations, and regulatory inquiries

• Monitor provider issues until resolution and provide status updates

• Assist in the implementation of network and operational initiatives impacting providers

• Prepare materials for providers, business summaries, issue analyses, and leadership briefings

• Ensure adherence to contractual obligations, regulatory standards, and company policies

• Contribute to special projects and cross-functional initiatives

⛳️ Requirements

• Minimum of 4 years of experience in healthcare operations, provider relations, network management, managed care, claims, provider services, or related healthcare fields

• Proven experience working directly with physicians, hospitals, ancillary providers, or healthcare organizations

• Experience in researching and resolving complex operational or provider-related challenges

• Strong analytical and problem-solving capabilities

• Comprehensive understanding of healthcare operations, including claims processing, provider enrollment, credentialing, provider data management, and reimbursement fundamentals

• Ability to collaborate effectively within a highly matrixed organization

• Excellent verbal, written, and presentation communication skills

• Capacity to manage multiple priorities simultaneously and achieve results in a dynamic environment

• Proficiency in Microsoft Excel, PowerPoint, and data analysis tools

• Bachelor's degree or an equivalent combination of education and relevant professional experience

• Experience supporting complex and strategic provider organizations

• Knowledge of Commercial, Medicare, Medicaid, and ACA products

• Experience in resolving provider claims and reimbursement concerns

• Experience managing provider disputes, executive complaints, regulatory inquiries, or escalated operational issues

• Familiarity with provider network operations, provider data management, credentialing, and enrollment processes

• Knowledge of value-based care programs and provider performance initiatives

• Experience with provider reporting, operational analytics, and root cause analysis

🏝️ Benefits

• Medical coverage

• Dental coverage

• Vision coverage

• Paid time off

• Retirement savings options

• Wellness programs

• Additional resources supporting physical, emotional, and financial well-being

• CVS Health bonus, commission, or short-term incentive program in addition to base salary