Specialist, Health Plan Provider Engagement

Job Title

Provides support for implementation of health plan provider engagement strategies and activities to drive necessary quality and risk adjustment outcomes. Uses a consultative approach, emphasizing physician engagement and behavior change through actionable data and analytics. Drives value-based care strategies through risk adjustment and quality improvement activities. Focuses on smaller, less advanced Tier 2 and Tier 3 providers, ensuring they have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans. Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitate data exchanges, and supports training and problem resolution for assigned providers - driving provider participation in Molina's risk adjustment and quality initiatives.

Essential Job Duties

• Provides support for provider engagement activities including enhancing value-based strategies, and risk adjustment/quality improvement initiatives.
• Ensures assigned Tier 2 and Tier 3 providers have a provider engagement plan to meet annual quality and risk adjustment performance goals.
• Drives provider partner coaching and collaboration to improve Medicaid, Medicare and Marketplace quality performance and risk adjustment accuracy through consistent provider meetings, action item development, and execution.
• Works with provider front-office staff to get the Molina members with the most open gaps on the schedule seen by their assigned provider. Coordinates with Health Plan Community and Member Engagement resources to drive supporting effort on the member side.
• Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes.
• Drives provider participation in Molina risk adjustment and quality efforts (e.g., supplemental data, electronic medical record (EMR) connection, clinical profiles programs) and use of the Molina provider collaboration portal.
• Tracks all engagement and training activities using standard Molina provider engagement tools to measure effectiveness both within and across Molina health plans.
• Serves as provider engagement subject matter expert; works collaboratively with health plan and shared service partners to ensure alignment to business goals.
• Collaborates with assigned health plan Provider Relations Network team member on operational, provider and member issues.
• Accountable for use of standard Molina Provider Engagement reports and training materials.
• Develops, organizes, analyzes, documents, and implements processes and procedures as prescribed by health plan and corporate policies.
• Communicates comfortably and effectively with internal and external stakeholders, including physician leaders, providers, practice managers, and medical assistants within assigned provider practices.
• Maintains the highest level of compliance.
• May require same day out-of-office travel up to 80% of the time, depending upon state/health plan requirements.

Required Qualifications

• At least 2 years of experience improving population-level HEDIS quality scores and burden of illness documentation accuracy through provider engagement, or equivalent combination of relevant education and experience.
• Experience with various managed health care provider compensation methodologies including but not limited to fee-for service (FFS), value-based care (VBC), and capitation.
• Working knowledge of quality metrics and risk adjustment practices across all business lines.
• Knowledge and understanding of HEDIS/NCQA and/or CMS STARs quality measures and risk adjustment practices across Medicaid, Medicare, and Marketplace
• Proficiency with data analysis, manipulation, interpretation, and reporting.
• Critical-thinking, problem-solving, and analytical skills.
• Relationship building skills.
• Attention to detail and organizational skills.
• Ability to implement process improvement initiatives and drive change.
• Ability to work independently in a fast-paced, deadline-driven environment.
• Ability to foster and build relationships in a cross-functional highly matrixed organization to obtain buy-in and drive results.
• Effective verbal and written communication skills.
• Microsoft Office suite (including Excel), Power BI, and other applicable software programs proficiency, and ability to learn new information systems and software programs.

Preferred Qualifications

• Bachelor's degree in Nursing, Health Administration or relevant discipline.
• Solid understanding of health insurance, provider messaging/design, and project management
• Strong experience using Microsoft products, including Excel (knowledge of pivot tables, VLOOKUP, etc.) and PowerPoint