Manager, Health Plan Provider Relations; Massachusetts

Job Summary

Molina Health Plan Network Provider Relations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Relations staff are the primary point of contact between Molina Healthcare and contracted provider network. In partnership with the Director, manages and coordinates the Provider Services activities for the state health plan.

Works with direct management, corporate, and staff to develop and implement standardized provider servicing and relationship management plans.

Manages the Plan’s Provider Relations functions and team members. Responsible for the daily operations of the department working collaboratively with other operational departments and functional business unit stakeholders to lead or support various Provider Services functions with an emphasis on contracting, education, outreach and resolving provider inquiries.

• In conjunction with the Director, Provider Network Management & Operations, develops health plan-specific provider contracting strategies, identifying specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of the Plan's patients or members.
• Oversees and leads the functions of the external provider representatives, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards.
• Manages and directs the Provider Service staff including hiring, training and evaluating performance.
• Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claim payment policies.
• Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards.
• Oversees appropriate and timely intervention/communication 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 Plan’s initiatives and help ensure regulatory requirements and strategic goals are realized.
• Ensures appropriate cross-departmental communication of Provider Service’s initiatives and contracted network provider issues.
• Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and Plan.
• Develops and implements strategies to increase provider engagement in HEDIS and quality initiatives.
• Engages contracted network providers regarding cost control initiatives, Medical Care Ratio (MCR), non-emergent utilization, and CAHPS to positively influence future trends.
• Develops and implements strategies to reduce member access grievances with contracted providers.
• Oversees the IHH program and ensures IHH program alignment with department requirements, provider education and oversight, and general management of the IHH program.
• 15-30% travel, mostly daytime, throughout Massachusetts.

Bachelor's Degree in Health or Business related field or equivalent experience.

• 5-7 years experience servicing individual and groups of physicians, hospitals, integrated delivery systems, and ancillary providers with Medicaid and/or Medicare products.
• 5+ years previous managed healthcare experience.
• Previous experience with community agencies and providers.
• Experience demonstrating working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicare or Medicaid lines of business, including but not limited to: fee-for-service, value-based contracts, capitation and delegation models, and various forms of risk, ASO, agreements, etc.
• Experience with preparing and presenting formal presentations.
• 2+ years in a direct or matrix leadership position.
• Min. 2 years experience managing/supervising employees.

Master’s Degree in Health or Business related field

• 5-7 years managed healthcare administration experience.
• Specific experience in provider services, operations, and/or contract negotiations in a Medicare and Medicaid managed healthcare setting, ideally with different provider types (e.g., physician, groups and hospitals).

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $76,425 - $149,028 / ANNUAL

* Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.