Executive Director, Medicaid Network Management

Job DescriptionThe position serves as an integral member of the National Medicaid Network leadership team and is responsible for providing leadership, guidance and oversight for all network management functions for assigned Medicaid Markets. This includes provider contracting, strategic relationships, provider engagement, and value based contracting strategy for Medicaid segment growth. The role will integrate provider network plans, strategies, activities, programs, policies and initiatives in order to effectively managing medical benefit costs while continually improving provider quality, access and Medicaid member satisfaction. Leads both managers and employees who develop, contract, maintain and enhance Medicaid provider networks which are of high quality and cost efficient to improve healthcare for our customers; builds relationships with facilities, physicians and ancillary providers which serve as contractual networks of care for members. Works in coordination with Value Based Care network management team to ensure the financial and operational performance of complex value based and accountable care arrangements to drive Medicaid Market performance. Works cross-functionally with Aetna Network Partners to align and/or execute network strategies. Oversees negotiations with the most complex and challenging contractual relationships. Maintains accountability for specific medical cost initiatives, unit cost budgets, discount improvement, and product/network expansions within a defined geography.Required Qualifications Leads and formulates the development and execution of market strategies that align with local and national business direction and their initiatives for Medicaid offerings. Communicates and drives his/her Network team to successful execution of the assigned tasks, strategies, and network objectives. Leads the design, development, management, and/or implementation of strategic network configurations that drive Medicaid Market performance. Leads and negotiates at the C-Suite level externally and internally with Key Medicaid Stakeholders. Builds and optimizes community based partnerships with providers. Develops and provides network strategy to support Medicaid procurement and Market engagement, along with assistance to achieve market and segment goals. Oversees and/or negotiates the most complex, competitive contractual relationships with providers according to prescribed guidelines in support of enterprise and Medicaid network strategies to achieve cost effective and best in class Medicaid competitive reimbursement rates. Overall accountability for contract negotiations involving all provider types for assigned Medicaid Markets. Provides a solid understanding and expertise in the End-to End aspects of provider contracting from contract modeling, configuration, utilization management, claims and analytics. Ensures Medicaid network adequacy and implements actions to build out network expansion markets and/or to close gaps. Act as SME, Mentor and Coach for his/her Network management managers and staff supporting ancillary and large physician group contracting. Constantly assesses opportunities for cost savings, alternate delivery models and financial risk sharing to enhance Medicaid competitiveness. Advance the company strategy to adopt value based Medicaid payment models including coordinates with VBC network team. Process may include to lead teams to develop, negotiate and manage complex Value Based and Accountable Care (ACO) relationships. Manage/attend Joint Operating Committee meetings with providers on VBC contracting arrangements. Collaborates with partners in sales, underwriting, medical economics and clinical leadership to develop an effective value based market strategy. Develop and present ACO value proposition and performance results in sales meetings or to external constituents. May have responsibilities related to network development in support of Joint Venture alliances. Negotiate complex contract language and initiate legal reviews as needed; ensure all required reviews completed by appropriate functional areas. Recommend and/or Approves and signs agreements in accordance with signature policy. Understands the Medicaid regulatory environment and ensures contractual compliance with federal and state requirements. Responsible for understanding medical cost issues and Medical Cost Ratios (MLRs) and initiating appropriate action to manage. Implementing initiatives and scoreable action items to reduce trends in medical costs. Partners with medical economics and clinical teams to assess opportunities, develop and execute action plans to manage cost trends and apply financial rigor. Develops and Drives improvement in market provider satisfaction results by partnering with medical management, finance and service operations. Develops, directs and maintains Medicaid relationships with external and internal care providers. Represents the organization at related external provider meetings and conferences as requested or as needed. Manages local Provider Relationship Management, Organization Orientation, Provider Advocacy groups. Respond to inquiries/issues generated by the provider service center, provider data services and other internal departments to address Medicaid claims issues, provider issues and member issues. Ensures high performing Medicaid Network teams through employee selection, development and performance management.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications 10 or more years experience in managed care, as well as leading and managing teams with at least 5 years Medicaid Contracting Experience. Demonstrated Network Management experience managing multiple states consecutively. 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 and demonstrated experience with managing value based strategies and population health management. Knowledge and experience with value based contracting negotiations and with execution of accountable care models. Command of financial modeling including medical cost management, network reimbursement models, MLR improvement. Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery systems and large physician groups. A successful track record managing and negotiating major provider contracts that improve competitive position. Knowledge of state Medicaid compliance and regulatory requirements. Proven ability to foster collaboration and operate in a heavily matrixed environment. Demonstrated experience for solid leadership skills including staff development.EducationBachelor's degree. MBA/Masters degree preferred.Business OverviewBring your heart to CVS HealthEvery 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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-01