Payer Relations Lead Coordinator at CVS Health

Cumberland, Rhode Island, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

2+ years of general experience

Responsibilities

Submits, maintains, and monitors applications for Initial enrollment and Revalidation with Government Medicaid Payer and Commercial Payers for Clinics and Providers to ensure active participation
Provides assistance in developing and improving payer workflow while ensuring compliance with the company's regulatory, safety, quality, and confidentiality protocols and standards
Ensures the timely and accurate submission of Group and Provider enrollment applications for Medicaid and Commercial programs, supporting compliance and operational efficiency across payer relations
Follows up on status and escalates as needed to overcome barriers and proactively address and resolve requests and issues
Minimizes the deactivation of government program applications by adhering to established quality control procedures
Serves as a key point of contact for escalated claim issues received from internal departments, coordinating with payers to identify and implement solutions, and communicates resolutions and relevant updates to appropriate internal stakeholders
Maintains accurate and up-to-date credentialing and billing systems by updating provider information upon inquiry or receipt from payers
Develops and maintains state-specific summaries, policies, procedures, and training modules to support operational consistency
Conducts research to identify potential issues, formulates solutions, and ensures timely resolution, communicating updates and relevant information to field teams as needed
Conducts research and analysis of trends related to claims, providers, and clinics to identify opportunities for process improvements and system efficiencies
Maintains a weekly issue log documenting all provider-payer issues by state
Collaborates with Senior and Centralized Provider Managers to ensure accurate provider enrollment across locations, reporting discrepancies and recommending corrective actions
Reviews claims on trends, errors, enrollment status, insurance package accuracy, and non-billable services to support resolution and operational integrity
Proactively contacts providers upon receipt of revalidation notices to obtain necessary documentation and verify current information
Manages escalations with field teams
Identifies and analyzes trends or issues related to payer enrollment, communicates findings and potential impacts to management, and implements strategies to minimize denials and application deactivations, reducing key metrics such as DSO, cost to collect, aged claims, and bad debt

Skills

Payer Enrollment

Medicaid Compliance

Commercial Payers

Credentialing

Revalidation

Provider Enrollment

Billing Systems

Claims Resolution

Quality Control

Audit Procedures

Trend Analysis

DSO Management

Escalation Management

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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