Director, Health Plan Provider Relations; Washington

JOB DESCRIPTION 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.

• 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 line 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…