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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

In this position, you will support the Provider Network Services legal and business teams with respect to a wide range of health care provider matters including, but not limited to: complex provider contract negotiations for Commercial, Medicare, Medicaid, and Specialty lines of business; pre-arbitration/litigation dispute resolution; credentialing, regulatory and risk management support; and general legal support for both participating provider networks and out of network providers in your assigned states. This support may range from tasks such as the following, as they relate to your assigned states:

Advising the business related to regulatory exams, inquiries, and filings where they involve provider network matters;

Advising, prioritizing, and mitigation planning regarding legal risks related to provider network relationships;

Providing provider contracting support, including support of complex provider health care system negotiations;

Working with the business and internal and external counsel to resolve provider disputes prior to arbitration/litigation;

Collaborating with the business on the development and review of sensitive internal and external communications to various stakeholders (senior executives, regulators, lawmakers, advocates, members);

Collaborating with Medicare and Medicaid counsel to implement federal and state specific legal research involving provider network services for government lines of business;

Serving as specific subject matter expert for assigned areas related to health care provider issues;

Providing day to day risk management support for internal business clients responsible for provider networks in your assigned region.

This position may also provide some support to Aetna Pharmacy Counsel (APC) and pharmacy business clients. This support may range from tasks such as the following:

Assisting with regulatory exams, inquiries, and filings where they involve pharmacy matters;

Collaborating with APC, Regional Counsel (RC), Compliance and business teams and conducting state specific legal research to assist with regulatory questions related to pharmacy matters;

Providing pharmacy related contracting support.

The attorney in this role will be expected to provide proactive risk management support and to assist in identifying and tracking policies and practices that can lead to various issues.  You will identify business and legal risks and provide solutions that balance legal issues and business objectives. You will be expected to develop a keen understanding of various operational systems and internal governance and to work diligently to develop and maintain positive relationships with various clients. 

Responsibilities

Contracting—Health Care Provider - 40%

-- Provide network contract and negotiation support as requested;

-- Provide MLR, PIP and other regulatory expertise as it relates to the development of new templates or the negotiation of current templates;

-- Coordinate with appropriate internal resources on any new or updated PADU language;

-- Draft new templates in response to business need;

-- Assist with negotiation of provider agreements.

 Dispute Resolution - 25%

-- Advise clients with respect to various member/provider demand letters and assist, as requested, with pre-arbitration/litigation dispute resolution;

-- Support business in its efforts to track and trend disputes for proactive dispute/litigation prevention;

-- Review and advise on legal issues associated with contract terminations.

Regulatory and General Support - 20%

-- In concert with RC and APC, advise clients with respect to the application of various state and federal laws and regulations including but not limited to ERISA, MHPAEA, fraud and abuse, and federal and state surprise billing and transparency laws and regulations;

-- Assist with various regulatory filings, as needed;

-- Assist in the coordination of answers to regulatory questions related to provider networks;

-- May provide pharmacy research as needed;

-- Work collaboratively with RC and APC, Compliance, Government Affairs and business operations teams to implement new laws and regulations;

-- Provide legal review for select communications;

-- Perform state specific research relating to issues raised while supporting network and pharmacy functions as requested.

New Products/Initiatives/Expansions - 15%

-- Provide guidance related to new products/initiatives/service area expansions;

-- Assist with review and comment on proposed and new regulations appliable to the scope of counsel provided to the business.

*The percentages are estimates of how your time and responsibilities may be divided, and might vary depending on need and the specific market and location. 

Required Qualifications

Juris Doctor from ABA-accredited institution required; Bar admission in good standing.

5+ years of legal experience.

3+ years of law firm, legal healthcare provider system, or government healthcare experience.

2+ years of provider or healthcare contracting experience.

Preferred Qualifications

Experience with Medicare and/or Medicaid regulatory landscape preferred;

MLR familiarity and experience preferred;

Litigation or other experience assisting with member and provider disputes preferred;

Experience working with state regulators and/or responding to state inquiries and exams preferred;

Knowledge of accreditation requirements—specifically NCQA preferred;

Knowledge of federal health care laws, including surprise billing, transparency and/or mental health parity preferred;

At least 2 years experience in a law firm health care practice; or in-house experience at a managed care company; or governmental experience preferred.

Demonstrated business judgment and acumen required;

Superior oral and written communication skills required; 

High level of interpersonal skills and ability to manage multiple responsibilities required.

Familiarity with healthcare regulations.

Pharmacy or PBM experience.

Education

Bachelor Degree and J.D.

Pay Range

The typical pay range for this role is:

$144,200.00 - $288,400.00

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 https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/30/2025

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