Director, Health Plan Provider Relations
Description JOB DESCRIPTION Job Summary - Leads and directs team responsible for health plan provider relations activities for the New York Health Plan. - 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. - Collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services for the health plan. Essential Job Duties - Oversees the plan’s provider relations function and team members. - Responsible for the daily operations of the department, including leading and supporting various provider relations activities including provider education, outreach and inquiry resolution. - Develops health plan-specific provider relations strategies - identifying specialties and geographic locations to concentrate resources for the purposes of establishing a sufficient network of participating providers to serve the health care needs of the plan's members, and successfully develop and refine cost-effective and high quality strategic provider networks - ensuring establishment of both internal and external long-term partnerships. - Collaborates with health plan network management 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. - Develops and deploys strategic network planning tools to drive provider services and contracting strategy across the organization. - Facilitates planning and documentation of network management standards and processes for all line of business. - Provides matrix team support including, but not limited to: new markets provider/contract support services, resolution support, and national contract management support services. - Builds and/or facilitates provider communication, training and education programs for internal staff, external providers, and other stakeholders. - Ensures compliance with applicable company/plan business requirements including state/federal statutes, government sponsored program requirements, and network access standards. - Oversees and leads provider representatives activities, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards. - Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claims payment policies. - Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards related to provider relations. - Oversees appropriate and timely interventions/communications when providers have issues or complaints (e.g., problems with claims and encounter data, eligibility, reimbursement, and provider website). - Serves as a resource to support the plan’s initiatives and helps to ensure regulatory requirements and strategic goals are realized. - Ensures appropriate cross-departmental communication of provider relations initiatives and contracted network provider issues. - Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and the plan. - Develops and implements strategies to increase provider engagement in Healthcare Effectiveness Data Information Set (HEDIS) and quality initiatives. - Engages 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. - Develops and implements strategies to reduce member access grievances with contracted providers. - Oversees the integrated health home (IHH) program and ensures IHH program alignment with department requirements, provider education and oversight. - Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration. Required Qualifications - At least 8 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. - At least 3 years of management/leadership 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. - Excellent verbal and written communication skills. - Microsoft Office suite and applicable software programs proficiency. Preferred Qualifications - 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