Provider Network Relationship Manager

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Evaluate the overall structure of the network and potential partner providers.

• Identify and manage partnerships that enhance and distinguish the OhioRISE Network.

• Implement, service, and possibly negotiate contracts with local market providers.

• Build and sustain productive relationships with assigned providers and internal business partners.

• Collaborate in creating business strategies and programs that align with operational plans.

• Address escalated issues and projects for the designated provider systems.

• Monitor performance metrics and adherence to scorecards and payout schedules.

• Educate both internal and external stakeholders on contract policies, plan design, compensation processes, technology, and performance evaluation.

• Conduct periodic meetings with key providers to ensure that service levels align with expectations.

• Create agendas, validate materials, and lead external provider meetings.

• Work together on the implementation of large provider systems, cost-driver management, data reporting, and cost initiatives.

• Promote provider engagement and recruit providers as necessary to meet network expansion and adequacy goals.

• Assist with strategic network configuration and integration efforts.

• Act as a subject matter expert for less experienced team members and internal partners.

⛳️ Requirements

• Over 5 years of experience in Medicaid managed care.

• Established history of working with individual providers and complex provider systems or groups.

• At least 2 years of experience in reviewing, analyzing, and auditing healthcare claims and claims data.

• Experience in identifying discrepancies, investigating and resolving claim issues, and providing insights to facilitate claims administration.

• Proficient in reviewing contracts for compliance with relevant state regulatory requirements.

• Ability to identify potential compliance issues and ensure that contractual terms conform to regulations and standards.

• Strong communication, critical thinking, problem-solving, and interpersonal skills.

• Must be a resident of the state of Ohio.

• Willingness to travel within Ohio as required.

• Proficient in MS Office Suite applications.

• Preferred in-depth knowledge of the behavioral health market.

• Preferred experience in building and maintaining relationships with behavioral health providers.

• Preferred in-depth understanding of the Ohio managed care market.

• Bachelor's degree preferred, or a combination of professional work experience and education.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.