Health Plan Provider Relations Manager (MA State Health Plan)

Job Title

Provides subject matter expertise and leadership for health plan provider relations activities.

Job Summary

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 provider community providers (including value-based payment (VBP) and other alternative payment method (APM) contracts 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 for non-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 including contracting, finance, quality, operations, and may 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.).

• Oversees and demonstrates accountability for provider satisfaction survey results.

• Develops and deploys strategic network planning tools to drive provider relations and contracting strategy across the enterprise.

• Facilitates strategic planning and documentation of network management standards and processes (effectiveness is tied to financial and quality indicators).

• Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practice sharing across the organization.

• Navigates the matrix team environment including: new markets provider/contract support services, resolution support, and national contract management support services.

• Serves as a subject matter expert for the provider relations function.

• Provides training, mentoring, and support to new and existing provider relations team members.

• Role requires 50%+ 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 6 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.

• 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.

• Strong verbal and written communication skills.

• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Management/leadership experience.

• 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