Executive Director, Network Management – OH/KY

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

At Aetna, our health benefits business, we are committed to helping our members achieve their best health in an affordable, convenient, and comprehensive manner. Combining the assets of our health insurance products and services with CVS Health’s unrivaled presence in local communities and their pharmacy benefits management capabilities, we’re joining members on their path to better health and transforming the health care landscape in new and exciting ways every day.

Aetna has an exciting opportunity to join its leadership team as an Executive Director, Network Management supporting our Ohio and Kentucky markets for our Commercial, Medicare, IFP, and Medicaid businesses. In this role, you will provide leadership, guidance, and oversight for a team of directors, negotiators, and consultants to ensure overall network competitiveness, service, and profitability for given market or geographical area. You will oversee all network management functions including provider contracting, service, strategic relationships, plan management, and the value based contracting strategy for growth.

You’ll make an impact by:

• Leading and developing the overall network and provider relations strategy for given area of responsibility (ie. defined geographic area) and drives teams to execution.
• Leading the design, development, management, and/or implementation of strategic network configurations that drive membership growth.
• Leading and negotiating at the C-Suite level externally and internally in the payer arenas.
• Developing, directing, and maintaining relationships with external and internal care providers and their organizations. Building and optimizing community-based partnerships.
• Providing network strategy support to sales and marketing, along with assistance on community relations related items to achieve market and segment goals.
• Overseeing and/or negotiating the most complex, competitive contractual relationships with providers according to prescribed guidelines in support of enterprise and local strategies.
• Overall accountability for contract negotiations, involving all provider types including at-risk arrangements, IPA/PHO, hospital, and large provider groups.
• Providing a solid understanding and expertise in the end- to-end aspects of provider contracting from modeling, configuration, utilization management, claims and analytics, including provider risk sharing.
• Negotiating complex contract language and initiate legal reviews as needed; ensure all required reviews are completed by appropriate functional areas.
• Supporting sales and retention efforts through finalist presentations and engagements with clients, prospects, brokers, and consultants.
• Ensuring network adequacy and implementing actions to build out network expansion markets and/or to close gaps.
• Advancing the company strategy to adopt value-based payment models; coordinates with VBC network team and/or may directly lead teams to develop, negotiate and manage complex Value Based and Accountable Care (ACO) relationships.
• May oversee the negotiation, implementation, and management of VBC agreements.
• Leading the Joint Operating Committee meetings for VBC arrangements.
• Representing the organization at related external provider meetings and conferences.
• May have responsibilities related to Joint Venture alliances.
• Working closely with Population Health resources to enable and improve clinical outcomes.
• Responsibility for understanding medical cost issues and medical cost ratios (MLRs) and initiating appropriate action to manage improvement initiatives and scoreable action items.
• Reviewing analytics with medical economics and working with providers to develop collaborative initiatives that improve quality results and manage costs.
• Driving improvement in market provider and member satisfaction results by partnering with medical management, marketing, finance, and service operations.
• Ensuring responses to inquiries/issues generated by the provider service center, provider data services and other internal departments to address claims issues, contract interpretation, provider, and complex member issues.
• Requiring communicating with internal/external parties by phone and/or in person; may require travel to offsite locations. Ensuring a wide variety of cross-functional Stars strategic initiatives remains on track.
• Ensuring innovation and integration of Stars industry best practices.
• Maintaining a pulse of external environment factors that may impact the Stars program, including CMS policy direction.
• Driving strategic goals/plan and messaging status to CVS and Aetna C suite, including resolving barriers and engaging decisionmakers.
• Identification of cross-enterprise initiatives necessary to achieve Stars and Member Experience objectives.
• Responsibility for providing guidance and direction to external consultants and cross-functional team members as required in support of initiatives.
• Stimulating strategic thinking in support of business direction.
• Providing information, expert opinion and thought leadership needed to support the attainment of Stars and Member Experience Objective.
• May represent the Stars organization at various forums (internal and external) or executive leadership briefings.
• Developing communication vehicles for presentations/ speeches.
• Developing issues relative to organization’s strategic direction.
• Identifying issues, coordinating analysis and initiation of corrective action.
• Managing special projects that impact Stars policies or strategic direction.
• Partnering effectively within the team and across the organization to ensure strategic initiatives stay aligned to plan and elevate solutions to barriers and decisions needed to executive leaders at the highest levels of organization.
• Supporting completion of policy/legislative analysis and response to new regulations/legislation.
• Preparing advocacy material for a variety of audiences.
• Supporting CVS Health in attracting, retaining, and engaging a diverse and inclusive consumer-centric workforce that delivers on our purpose and reflects the communities in which we work, live, and serve.

Required Qualifications

The candidate will have a strong work ethic, be a self-starter, and be able to be highly productive in a dynamic, collaborative environment. This position offers broad exposure to all aspects of the company’s business, as well as significant interaction with all the business leaders. The candidate will be expected to have the following key attributes:

• Person must reside within Ohio or Kentucky.
• 10+ years of experience in managed care; leading and managing teams.
• Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers.
• In-depth knowledge of various reimbursement structures and payment methodologies for both hospitals and physicians.
• Comprehensive understanding of value-based strategies and population health management, and Aetna’s related strategic initiatives.
• Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery systems and large physician groups.
• May require knowledge of MACRA and other government programs (ex. Bundled payments) depending on market.
• Solid leadership skills including staff development.
• Understands the regulatory environment and ensures contractual compliance with federal and state requirements.
• Demonstrated a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.

Preferred Qualifications

• Demonstrated experience with contracting for Commercial, Medicare, IFP and Medicaid lines of business.
• Advanced degree in applicable field.

Education

Bachelor’s degree required/specialized training/relevant professional qualification.

Pay Range

The typical pay range for this role is:

$131,500.00 – $303,200.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.  This position also includes an award target in the company’s equity award program. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. 
 
For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 05/31/2024