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Job Summary
Leads and directs team responsible for health plan provider relations activities. Supports network development, network adequacy and provider training and education. Serves as primary point of contact between the business and contracted providers within the Molina network. Responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina policies and procedures. Collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services for the health plan.
Essential Job Duties
Oversees the plan’s provider relations function and team members. Responsible for the daily operations of the department, including leading and supporting various provider relations activities including provider education, outreach and inquiry resolution.
Develops health plan-specific provider relations strategies - identifying specialties and geographic locations to concentrate resources for the purposes of establishing a sufficient network of participating providers to serve the health care needs of the plan's members, and successfully develop and refine cost-effective and high-quality strategic provider networks - ensuring establishment of both internal and external long-term partnerships.
Collaborates with health plan network management and operations teams and functional business unit stakeholders to lead and/or support various provider services functions and strategic initiatives with an emphasis on developing and implementing standards, resources, tools and best practices sharing across the organization.
Develops and deploys strategic network planning tools to drive provider services and contracting strategy across the organization. Facilitates planning and documentation of network management standards and processes for all lines of business.
Provides matrix team support including but not limited to: new markets provider/contract support services, resolution support, and national contract management support services.
Builds and/or facilitates provider communication, training and education programs for internal staff, external providers, and other stakeholders.
Ensures compliance with applicable company/plan business requirements including state/federal statutes, government sponsored program requirements, and network access standards.
Oversees and leads provider representatives activities, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards.
Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claims payment policies.
Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards related to provider relations.
Oversees appropriate and timely interventions/communications when providers have issues or complaints (e.g., problems with claims and encounter data, eligibility, reimbursement, and provider website).
Serves as a resource to support the plan’s initiatives and helps to ensure regulatory requirements and strategic goals are realized.
Ensures appropriate cross-departmental communication of provider relations initiatives and contracted network provider issues.
Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and the plan.
Develops and implements strategies to increase provider engagement in Healthcare Effectiveness Data Information Set (HEDIS) and quality initiatives.
Engages contracted network providers regarding cost control initiatives, medical cost ratio (MCR), non-emergent utilization, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to positively influence future trends.
Develops and implements strategies to reduce member access grievances with contracted providers.
Oversees the integrated health home (IHH) program and ensures IHH program alignment with department requirements, provider education and oversight.
Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration.
Required Qualifications
At least 8 years of provider services experience, including experience supporting individual/group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid, Medicare, and or Marketplace products, or equivalent combination of relevant education and experience.
At least 3 years of management/leadership experience.
Strong understanding of the health care delivery system, including government-sponsored health plans.
Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including: fee-for service (FFS), capitation and various forms of risk, ASO, etc.
Previous experience with community agencies and providers.
Strong organizational skills and attention to detail.
Ability to manage multiple tasks and deadlines effectively.
Experience with preparing and presenting formal presentations.
Strong interpersonal skills, including ability to interface with providers and medical office staff.
Ability to work in a cross-functional highly matrixed organization.
Excellent verbal and written communication skills.
Microsoft Office suite and applicable software programs proficiency.
Preferred Qualifications
Contract negotiation experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
