JOB DESCRIPTION Job Summary

Provides subject matter expertise and leadership for enterprise network management and operations activities including 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

• Develops and deploys network planning tools to drive provider services and contracting strategy across the enterprise. 
• Facilities planning and documentation of network management standards and processes.
• In conjunction with national provider services leadership, develops standards and resources to help Molina health plans successfully develop and refine cost-effective and high-quality strategic provider networks, establishing both internal and external long-term partnerships.
• Collaborates with health plan network leadership and operations teams and functional business unit stakeholders to lead and/or support various provider services functions and strategic initiatives with an emphasis on developing and implementing standards, resources, tools and best practices sharing across the organization.
• In conjunction with national provider services leadership, develops and deploys strategic network planning tools to drive provider services and contracting strategies across the organization; facilitates planning and documentation of network management standards and processes for all line of business.
• Supports development of national network management and operations provider contracting strategies - identifying specialties and geographic locations to concentrate resources for purposes of establishing a sufficient network of participating providers to serve the health care needs of Molina members.
• Assists with ongoing enterprise-wide provider network development and the education of contracted network providers regarding various health plan procedures and claims payment policies.
• Develops and implements tracking tools to ensure timely issue resolution and compliance with all network-related standards.
• Ensures appropriate and timely intervention/communication when providers have issues or complaints (e.g. claims and encounter data, eligibility, reimbursement, and provider website).
• Serves as a resource to support health plan initiatives and help ensure regulatory requirements and strategic goals are realized.
• Ensures appropriate cross-departmental communication of provider network initiatives and contracted network provider issues.
• Designs and implements enterprise-wide programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and health plans.
• In conjunction with national provider services leadership, develops and implements enterprise-wide strategies to increase provider engagement in Healthcare Effectiveness Data Information Set (HEDIS) and quality initiatives.
• Provides matrixed team support including:  new markets provider/contract support services, resolution support, and national contract management support services.
• Builds, drafts and/or performs provider communications, training and education programs for internal staff, external providers, and other stakeholders.
• Develops and implements strategies to reduce member access grievances with contracted enterprise providers.
• Engages enterprise-wide contracted network providers regarding cost-control initiatives, medical cost ratio (MCR), non-emergent utilization, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to positively influence future trends.
• Ensures compliance with applicable company/plan business requirements including state/federal statutes, government sponsored program requirements, and network access standards.
• Serves as a national provider services subject matter expert.
• Provides training, mentoring and support to new and existing provider services team members.
 

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.
• Strong interpersonal skills, including ability to interface with providers and medical office staff.
• Experience with preparing and presenting formal presentations.
• Project management experience.
• 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