Health Plan Provider Relations Manager (Remote in IL)

Job Overview

Job Summary Provides subject matter expertise and leadership 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.

Job Description

• 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.

Key Responsibilities

• Job Summary Provides subject matter expertise and leadership for health plan provider relations activities.
• Supports network development, network adequacy and provider training and education.
• 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.
• Resolves complex provider issues that may cross departmental lines including contracting, finance, quality, operations, and may involve senior leadership.
• 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.).

Required Skills and Qualifications

• Responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina policies and procedures.
• 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.
• 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.
• 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.
• Experience with preparing and presenting formal presentations.
• Strong interpersonal skills, including ability to interface with providers and medical office staff.

Benefits and Perks

• Molina Healthcare offers a competitive benefits and compensation package.

Work Location and Schedule

This role is listed as Remote USA with location information shown as Remote USA. The employment type is Full Time.

About the Company

Molina Healthcare is the organization connected with this listing. USA Jobs Today displays this opportunity for job discovery only, so applicants should verify company details, application instructions, and eligibility on the official employer website.