Lead Director, Provider Experience Standardization

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 Lead Director, Provider Experience Standardization is responsible for ensuring the variations that currently exist across multiple Health plans specific to provider contracting, credentialing, provider onboarding, loading and maintenance are standardized and documented, with strong data entry control points to drive alignment and transparency with the Network Operations Team and the Health Plans.  This leader will execute on the Process Standardization strategy by developing and defining the standard workflows to use for new market implementations and expansions, as well as define the process to transition each Health Plan from current state to the new standard.

This position will require continuous collaboration and consultation with complex, cross-functional stakeholder management, to ensure the desired business outcome is defined and achieved.

The ideal candidate is an initiative-taker, detail-oriented, highly organized and must exhibit strong communication and process improvement skills, with a deep understanding of Medicaid network, credentialing and provider data processes.

Key Responsibilities

Leading the execution of process mapping, workflows, audit and controls for core Network processes such as Intake, Credentialing, Provider Data Loading, Rosters, Non-Par Loads, Provider Terminations, Market Expansions and Implementations, and Deeming, including but not limited to the following:

• Design a uniformed review and control process for provider data loads and update requests / submission to ensure strong data entry control points and help drive alignment with the Network Operations Team and the Health Plans
• Enhance the bulk load process to load and update provider data within QNXT, streamlining the process to complete the spreadsheet inputs efficiently
• Implement a PRMS mailbox specific for Value Based Care providers to ensure requests are resolved appropriately by Analysts that are familiar with VBC requirements
• Advance a PRMS dashboard in which Health Plans have access to so they can track the progress / status of their requests and requests submitted by providers
• Develop a formal process and capacity to conduct periodic provider outreach to ensure accuracy of provider data and directories.
• Develop a formal process to conduct PCR audits and ProData audits to identify trends and determine opportunities for training / education
• Develop a formal process for member reassignments or member / provider communication when members’ PCPs are terminated
• Review active prior authorizations and inform the UM/CM departments prior to the completion of the termination to ensure continuity of care
• Leverage the Provider Assessment Report to proactively identify and address provider data issues
• Create and run controls such as SQL queries and analytics at regular intervals to proactively identify and address provider data issues
• Recommend prioritization of technology investment pipeline to support migration to standard workflows
• Define plan to align capabilities and processes across lines of business

Required Experience:

• 10+ years managed care / network / health insurance industry experience.
• Demonstrated experience successfully driving change in complex organizations.
• Demonstrated relationship management skills at the senior level; capacity to quickly build and maintain credible relationships at varying levels of the organization simultaneously.
• Experience with enterprise-wide and/or cross-functional large-scale initiatives with high degree of complexity.
• Demonstrated leadership with relevant initiatives: Business process, enterprise business project management/consulting, and/or strategic planning.
• Strong quantitative skills with ability to structure, analyze, and interpret data to identify trends and draw logical conclusions; propensity toward supporting hypothesis with strong quantitative and qualitative evidence.
• Comfort with ambiguity, ability to create a process where one doesn’t exist and deliver results
• Strong experience creating and telling a story using Power Point.

Preferred Experience:

• QXNT experience.
• Six Sigma trained or certified.

Education:

• Bachelor's degree or equivalent professional work experience.