Health Plan Provider Contracts Manager - Complex

Job Description

Provides subject matter expertise and leadership for health plan provider network complex contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Responsible for negotiating agreements, including value-based payment methodology, with complex provider groups that are strategically critical to plan success, including but not limited to: hospitals, hospital systems, and behavioral health organizations.

• Negotiates contracts and letters of agreement with the complex provider community to secure high quality, cost-effective and marketable plan providers.

• Contracts/re-contracts with large-scale entities involving custom reimbursement; executes standardized alternative payment model (APM) contracts; issues escalations, and supports network adequacy, joint operating committees (JOCs), and delegation oversight.

• Execution, management, and optimization of value-based contracts and enhanced provider relationship management.

• Directs analysis of financial impact of deal terms and prepare details and justification for executive approval for agreements outside of Molina approval guidelines.

• In conjunction with contracting leadership, negotiates complex provider contracts including high-priority physician group and facility contracts using preferred, acceptable, discouraged, unacceptable (PADU) guidelines (emphasis on number or percentage of membership in value-based relationship contracts).

• Develops and maintains provider contracts in contract management software.

• Targets and recruits additional providers to reduce member access grievances.

• Engages targeted contracted providers in renegotiation of rates and/or language; assists with cost-control strategies that positively impact the medical cost ratio (MCR) within each region.

• Advises network contracting team members on negotiation of individual provider and routine ancillary contracts.

• Maintains contractual relationships with significant/highly visible providers.

• Evaluates provider network and implement strategic plans with the goal of meeting Molina's network adequacy standards.

• Assesses contract language for compliance with corporate standards and regulatory requirements and review revised language with assigned corporate attorney.

• Participates in fee schedule determinations including development of new reimbursement models; seeks input on new reimbursement models from corporate network leadership, legal and senior level engagement as required.

• Educates internal customers on provider contracts.

• Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital and ancillary providers.

• Participates with the leadership team and other committees to address the strategic goals of the department and organization.

• Participates in contracting-related special projects as directed.

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

• Travels approximately 5-10% within designated Massachusetts regions.

• At least 5 years of experience in network contracting with large specialty or multispecialty provider groups, and at least 3 years experience in provider contract negotiations in a managed health care setting ideally negotiating different provider contract types (i.e. physician/group/hospital), or equivalent combination of relevant education and experience.

• Working familiarity with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: value-based payment (VBP), fee-for service (FFS), capitation and various forms of risk, etc.

• Negotiation and relationship building capabilities.

• Ability to navigate complex regulatory environments.

• Data-driven decision-making skills, and analytical abilities.

• Organizational skills and attention to detail.

• Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization.

• Ability to manage multiple tasks and deadlines effectively.

• Effective verbal and written communication skills.

• Microsoft Office suite and applicable software programs proficiency.

• Contracting experience with integrated delivery systems, hospitals and groups (specialty and ancillary).

• Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.