Network Development and Contracting (Value Based Care) Medicaid (NJ/PA/NY)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

• The Medicaid VBS Network State Manager manages and oversees compliance with our Network responsibilities as provided within the State Medicaid contractual requirements as outlined below: 
• Accountable for working with our strategic provider partners to promote innovative value-based solutions to meet total cost and quality goals for our Medicaid businesses.
• Responsible for deploying alternative payment models, executing new initiatives, and negotiating value-based contracts with the templated payment structures, which requires:
• Basic understanding the providers’ volume and cost structure
• Conducting negotiation following PADU tool, and
• Aligning negotiation tactics with goals encompassing network accessibility, quality, compliance and financial performance.
• Works with Practice Transformation Team, VBS reporting team and other key internal teams to develop a value based strategic plan and manage contract performance with targeted provider groups to ensure we meet state guidelines for value based provider agreements.
• In charge of complete value based contracting cycle from planning, creating documents, and negotiation to oversee loading of executed arrangements. That includes, but not limited to:
• Recruits providers to ensure attainment of network expansion and adequacy targets.
• Accountable for negotiation of payment arrangements with providers and operation ability of the established contracts.
• Oversees the monitoring and loading of executed value-based provider contracts to ensure State requirements.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve value-based contracting targets and manage medical costs through effective value-based contracting to meet state contract and product requirements.
• This Position will manage combined functions for external provider engagement representatives and internal provider relations representatives to ensure successful Provider Relationships, and Network Performance including Clinical and Affordability Targeted Improvements as identified.  That includes, but not limited to:
• Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners.
• Continuous review of value based provider performance and movement of providers along the value based continuum as they are ready.
• Recommend training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed.
• Collaborates with internal partners to assess effectiveness of tactical plan in managing costs. May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met.
• Facilitates and attends, as needed, including Traveling externally when required for, Provider meetings and negotiations.
• Coordinate’s provider information with member services and other internal departments as requested.
• 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.

• Minimum of 7 years recent Managed Care Network Value Based Contacting experience with 2-3 years Medicaid Network experience
• Must have Microsoft Office experience with intermediate to advanced Excel and PowerPoint skills
• 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
• Proven ability to work in a matrixed organization
• Candidates are to reside within applicable State
• This is a work at home position, with ability to travel within the state to visit providers or to main office in Aetna Office Locations applicable to the Market

• Familiar with legal terms in the context of provider contracting
• Able to apply system thinking when managing multiple provider value-based initiatives
• Strong financial modeling background

• Bachelor’s degree or equivalent professional working experience.

The typical pay range for this role is: