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Our work matters. We help people get the medicine they need to feel better and live well. It fuels our passion and drives every decision we make. The Network Management Consultant is responsible for the development, performance and management of Prime's retail, mail, specialty, and quality-based networks aligning with Prime's Supply Chain Cost of Goods Sold (COGS) and network management strategies. This includes development of network contracts, participation requirements, analysis of pharmacies, and ensuring contract and regulatory compliance. This position is accountable for creation and management of specialty fee schedules to ensure competitiveness and serves as the liaison between Prime's Network Management and Specialty teams.

Responsibilities include: negotiating market competitive high-profile and/or complex pharmacy agreements across all channels including retail, mail, specialty and quality based and lines of business aligning with Supply Chain COGS strategies; leading and managing specialty fee schedule development process and ensuring fee schedule revisions align with Supply Chains COGS strategies for specialty drug management; leading and implementing network initiatives by facilitating and performing network analyses, contracting activities and fee schedule development aligning with strategy, priorities and project goals; partnering with Prime's reporting and analytics teams to develop network vendor loading rules inclusive of approved preferred and specialty pharmacies; maintaining key compliance criteria and implementing quarterly reporting processes for all contracted network specialty pharmacies; analyzing network specialty pharmacy quarterly reports to ensure compliance with reporting and participation requirements; collaborating with Specialty Clinical Program Directors to identify potential performance gaps; working with internal and external partners to develop and manage corrective action plans; managing the pharmacy contract from negotiation of all terms, ensuring Prime and Pharmacy compliance and document retention aligning with Prime's Record Information Management (RIM) policies; working closely with Prime's legal team to update contract documents including agreements and applications for utilization in contracting/re-contracting activities based on new network participation requirements; and other duties as assigned.

Bachelor's degree in business or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required. 8 years of Network Management experience within Pharmacy Benefit Management (PBM), healthcare or other highly regulated industry; including 5 years of managed care experience in medical or pharmacy network contracting. Must be eligible to work in the United States without need for work visa or residency sponsorship.

Excellent verbal and written presentation skills. Demonstrated understanding of network reporting and analysis for specialty pharmacy. Demonstrated ability to establish trust and credibility; form working relationships with all levels of an organization. Demonstrated ability to work independently and on highly complex contract language and agreements; strong attention to detail. Enhanced organizational skills with the ability to work on multiple projects simultaneously. Demonstrated ability to problem solve and interpret complex data; ability to analyze network information and synthesize it into meaningful information for a variety of audiences. Ability to work with confidential data and maintain privacy.

Master's degree in business, healthcare or related area of study. Demonstrated understanding of retail and specialty network fee schedule management. 2 years of experience in specialty contracting. PBM or Healthcare experience.

Ability to travel up to 15% of the time. Constantly required to sit, use hands to handle or feel, talk and hear. Frequently required to reach with hands and arms. Occasionally required to stand, walk and stoop, kneel, and crouch. Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Our work matters. We help people get the medicine they need to feel better and live well. It fuels our passion and drives every decision we make. The Network Management Consultant is responsible for the development, performance, and management of Prime's retail, mail, specialty, and quality-based networks aligning with Prime's Supply Chain Cost of Goods Sold (COGS) and network management strategies. This includes development of network contracts, participation requirements, analysis of pharmacies, and ensuring contract and regulatory compliance. This position is accountable for creation and management of specialty fee schedules to ensure competitiveness and serves as the liaison between Prime's Network Management and Specialty teams.

Responsibilities include:

• Negotiating market competitive high-profile and/or complex pharmacy agreements across all channels including retail, mail, specialty, and quality based and lines of business aligning with Supply Chain COGS strategies
• Leading and managing specialty fee schedule development process and ensuring fee schedule revisions align with Supply Chains COGS strategies for specialty drug management
• Leading and implementing network initiatives by facilitating and performing network analyses, contracting activities, and fee schedule development aligning with strategy, priorities, and project goals
• Partnering with Prime's reporting and analytics teams to develop network vendor loading rules inclusive of approved preferred and specialty pharmacies; maintaining key compliance criteria and implementing quarterly reporting processes for all contracted network specialty pharmacies
• Analyzing network specialty pharmacy quarterly reports to ensure compliance with reporting and participation requirements; collaborating with Specialty Clinical Program Directors to identify potential performance gaps; working with internal and external partners to develop and manage corrective action plans
• Managing the pharmacy contract from negotiation of all terms, ensuring Prime and Pharmacy compliance and document retention aligning with Prime's Record Information Management (RIM) policies
• Working closely with Prime's legal team to update contract documents including agreements and applications for utilization in contracting/re-contracting activities based on new network participation requirements
• Other duties as assigned

Education & Experience:

• Bachelor's degree in business or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
• 8 years of Network Management experience within Pharmacy Benefit Management (PBM), healthcare, or other highly regulated industry; including 5 years of managed care experience in medical or pharmacy network contracting
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications:

• Excellent verbal and written presentation skills
• Demonstrated understanding of network reporting and analysis for specialty pharmacy
• Demonstrated ability to establish trust and credibility; form working relationships with all levels of an organization
• Demonstrated ability to work independently and on highly complex contract language and agreements; strong attention to detail
• Enhanced organizational skills with the ability to work on multiple projects simultaneously
• Demonstrated ability to problem solve and interpret complex data; ability to analyze network information and synthesize it into meaningful information for a variety of audiences
• Ability to work with confidential data and maintain privacy

Preferred Qualifications:

• Master's degree in business, healthcare, or related area of study
• Demonstrated understanding of retail and specialty network fee schedule management
• 2 years of experience in specialty contracting
• PBM or Healthcare experience

Physical Demands:

• Ability to travel up to 15% of the time
• Constantly required to sit, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk, and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus

Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.

Thank you for your interest in joining our team! Please review the job information below.

General Purpose of Job: The Credentialing/Network Management Program Coordinator is responsible for managing efforts to ensure compliance with industry-standard accreditation programs, specific to health plan Credentialing and Network Management activities. In addition, the role is responsible for monitoring Credentialing operational processes to ensure continual adherence to accreditation requirements.

Essential Duties and Responsibilities:

• Maintains the utmost level of confidentiality at all times.
• Adheres to Health System and Health Plan policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Communicates in both written and oral form with contracted professionals, individuals, vendors, and agencies both inside and outside of the Health Plan, in order to obtain or relay information.
• Ensures that projects are completed on time, and with a high degree of quality.
• Designs, implements, and manages a structured URAC accreditation management plan, including continuous readiness activities, focused on Provider Network Management and Credentialing.
• Provides regular reports to business owners and leadership on the status of departmental accreditation management plans and readiness.
• Evaluates, interprets, and summarizes accreditation guidelines and manages the process for accreditation activities specific to Provider Network Management and Credentialing.
• Collaborates with business owners, demonstrating positive change management with a servant leadership approach to establish trust and build productive relationships, to facilitate the application of relevant standards to existing or new required documentation (plans, evaluations, policies, and procedures).
• Develops and implements work plans to guide business owners/team leads on activities required to ensure ongoing compliance for assigned functions, focused on Provider Network Management and Credentialing; meets with business owners/team leads regularly to assess progress and review documentation; revises work plans based on results as needed and conducts quality checks of all documents before submission to applicable accrediting/regulatory bodies.
• Coordinates all facets of the URAC accreditation/approval process including ensuring all activities, documentation, and evidence necessary for the accreditation are prepared in compliance with accreditation standards, specific to Provider Network Management and Credentialing.
• Conducts internal credentialing audits to ensure continuous audit preparedness, identify opportunities for improvement and actions required, communicate results to business owners/team leads, and report results to management.
• Monitors corrective action plan progress. Relative to Provider Network Management and Credentialing ensuring compliance and timely closure.
• Maintains URAC internal policies and procedures, specific to Network Management and Credentialing, in consultation with others; updates existing and creates new policies and procedures as necessary.
• Manages and maintains the Health Plan Provider Directory, both printed and online; routinely audits the Directory to ensure appropriateness/correctness of provider data
• Manages and maintains the Health Plan Provider Manual; ensures compliance with all regulatory requirements.
• Other duties as needed to support business operations.

Education and/or Experience:

• Bachelor's degree from a four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.
• At least 5 years of experience in Managed Care experience in Credentialing and/or Network Management.
• 3-5 years of related health plan URAC accreditation experience, specific to Credentialing and/or Network Management.
• Strong written and verbal communication skills with a focus on detail and concise, objective, relevant documentation.
• Demonstrated skills in Microsoft Office Word, Excel, Visio, and PowerPoint; willingness to learn/train to develop further proficiencies as related to job duties.
• The ability to accelerate impact and effectively collaborate across multiple teams toward attaining common goals and objectives.
• Ability to prioritize work, set expectations, meet deadlines, and produce consistent, quality work on time.

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.

*Preference is for candidate to reside in the Eastern Time Zone

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 Management/Contract negotiation International Vendor management

• Operations Management (Claim, Customer Service)

• Additional spoken languages preferred

ADDITIONAL JOB INFORMATION

Opportunity to work in a fast pace, growing and exciting international arena supporting key Aetna International clients and managing critical Aetna vendors.

Pay Range

The typical pay range for this role is:

$67,900.00 - $199,144.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit

We anticipate the application window for this opening will close on: 09/30/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. 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.