Senior Manager - Provider Network Management

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.

POSITION SUMMARY

This position is fully dedicated to a GLOBAL VIP CLIENT. An ideal candidate for this position will manage competitive and complex contractual relationships with Third Party Administrators (TPAs) and/or business partners in Europe, APAC and Africa in support of an international network, medical cost management and overall claim/customer service strategies. This role will provide concierge level of service to GLOBAL VIP CLIENT members via timely provision of required network access and proactive management of network relationships to ensure seamless direct settlement access.

JOB RESPONSIBILITIES:

• Play a critical role in setting up 10+ direct TPAs setup for GLOBAL VIP CLIENT in the next 12 months’ time frame.
• Manage TPA relationships with external vendors and own overall relationship with assigned TPAs in Europe, Africa and APAC region.
• Oversee and manage contractual relationship with assigned TPA(s).
• Manage Third Party Risk Governance process for your assigned TPA(s).
• Manage ongoing Aetna compliance review process for your assigned TPA(s).
• Manage monthly billing / submission of TPA invoices for timely payment and float management.
• Ensuring service level adherence (GOP TAT, eligibility processing, claim TAT, reconciliation TAT, fee invoicing etc)
• Ensure TPA networks are timely reviewed and uploaded on internal Aetna systems.
• Ensure TPA guides, country guides and other internal materials are timely updated and up to date.
• Ensuring streamline GLOBAL VIP CLIENT experience at each country level. Evaluate network options, network efficacies and optimize network utilization to increase direct billing.
• Ensure setup / maintenance of claim file, eligibility file, provider data file and changes.
• Lead operational vendor improvements (eg. Claim BOTs, portal utilization, provider data from via API etc)
• End to end ownership of operational issues originating from assigned TPAs and work towards swift resolutions.
• Effectively negotiates and manages complex, competitive contractual relationships with providers according to prescribed guidelines in support of global and regional network strategies. Expand International provider network by contracting new direct pay providers and manage overall contracting process.
• Serve as a subject matter expert to assist the internal GLOBAL VIP CLIENT account management team with network and TPA questions or inquiries. Provide support to peers and colleagues working on GLOBAL VIP CLIENT business.
• Oversee and manage any operational issues and queries regarding your assigned TPA(s).
• Manage day to day provider operations, either direct or through network business partners. Ensures operational efficiency for all network processes and infrastructure through proactive provider education and collaboration with Aetna International Service Operations
• Executes regional-specific strategies and tactics in response to market expectations.
• Executes GLOBAL VIP CLIENT specific strategies and tactics for key expatriate clients.
• Responsible for understanding and managing medical cost issues and initiating appropriate action from the provider perspective.
• Key contributor to enhanced provider service solution like provider portal and other digital solution, including development and/or management of process and technical support.
• Initiate legal reviews as needed; ensure all required reviews completed by appropriate functional areas

REQUIRED SKILLS:

• 7+ years experience negotiating and managing vendor and provider agreements
• Strong project management skills
• Excellent written and verbal communication skills
• Ability to leverage technology to achieve quality and cost efficiencies
• Prior client facing experience
• Benefits Management/Interacting with Medical Professionals

EDUCATION

Bachelor's degree or equivalent experience.

Masters preferred but not required.
 

DESIRED SKILLS

• Leadership/Fostering a Global Perspective
• Health Insurance understanding / business negotiations
• Service/Demonstrating Service Discipline
• International Network Managemen