Senior Provider Relations Representative

Job Title

Provides senior level support for health plan provider relations activities.

Job Summary

Provides senior level support 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.

Essential Job Duties

Successfully engages the plan's highest priority, high-volume and strategic complex community providers to ensure provider satisfaction, facilitate education on key Molina initiatives, and improve coordination and partnership between the health plan and contracted providers. Serves as the primary point of contact between Molina health plan and the complex provider community that services Molina members, including but not limited to fee-for-service (FFS) and pay-for-performance (P4P) providers. Collaborates directly with the plan's external providers to educate, advocate and engage as valuable partners - ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service; effectively drives timely issue resolution, electronic medical record (EMR) connectivity, and provider portal adoption. Resolves complex provider issues that may cross departmental lines and involve senior leadership. Conducts regular provider site visits within assigned region/service area; determines daily or weekly schedule, to meet or exceed the plan's monthly site visit goals. Proactively engages with the provider and staff to determine; for example, non-compliance with Molina policies/procedures or Centers for Medicare and Medicaid Services (CMS) guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members. Provides on-the-spot training and education as needed, including counseling providers diplomatically, while retaining a positive working relationship. Independently troubleshoots provider problems as they arise, and takes initiative in preventing and resolving issues between the provider and the plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters. Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians (examples include: issues related to utilization management, pharmacy, quality of care, and correct coding). Independently delivers training and presentations to assigned providers and their staff - answering questions that come up on behalf of the health plan; may also deliver training and presentations to larger groups, such as leaders and management of provider offices, including large multispecialty groups or health systems, executive level decision makers, association meetings, and joint operating committees (JOCs). Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives; examples of such initiatives include: administrative cost-effectiveness, member satisfaction - Consumer Assessment of Healthcare Providers and Systems (CAHPS), regulatory-related, Molina quality programs, and taking advantage of electronic solutions (electronic data interchange (EDI), EMR, provider portal, provider website, etc.). Serves as a subject matter expert for the provider relations function. Provides training and support to new and existing provider relations team members. Role requires 80%+ same-day or overnight travel (extent of same-day or overnight travel will depend on the specific health plan service area).

Required Qualifications

At least 3 years of customer service, provider services, or claims experience in a managed care or medical office setting, or equivalent combination of relevant education and experience. Understanding of the health care delivery system, including government-sponsored health plans. Understanding of 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. Experience delivering training and facilitating educational presentations. Organizational skills and attention to detail. Ability to manage multiple tasks and deadlines effectively. Interpersonal skills, including ability to interface with providers and medical office staff. Ability to work in a cross-functional highly matrixed organization. Effective verbal and written communication skills. Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

Experience in provider services, operations, and/or contract negotiations in a Medicaid, Medicare, and/or Marketplace managed health care setting - ideally with different provider types (i.e. physician, group, hospital).

Job Info

• Job Identification 2038866
• Job Category Network
• Locations Columbia, SC, United States
• Salary Range $47,433.00 - $97,362.61 Annually *Actual compensation may vary based on geographic location, work experience, education and/or skill level