Senior Representative, Health Plan Provider Relations - Remote

JOB DESCRIPTION Job Summary

Provides senior level support 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. 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 community providers to ensure provider satisfaction, facilitate
education on key Molina initiatives, and improve coordination and partnership
between the health plan and contracted providers.
• Serves as the primary point of contact between Molina health plan and the
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 and 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.
• Independently troubleshoots provider problems as they arise, and takes
initiative in preventing and resolving issues between the provider and the plan
whenever possible. The types of questions, issues or problems that may emerge
during visits are unpredictable and may range from simple to very complex or
sensitive matters.
• 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.).
• Serves as a subject matter expert for the provider relations function.
• Provides training and support to new and existing provider relations team
members.
• Role requires 80%+ same-day or overnight travel (extent of same-day or
overnight travel will depend on the specific health plan service area).

Required Qualifications

• At least 3 years of customer service, provider services, or claims experience
in a managed care or medical office setting, or equivalent combination of
relevant education and experience.
• Understanding of the health care delivery system, including
government-sponsored health plans.
• Understanding of 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.
• Experience delivering training and facilitating educational presentations.
• Organizational skills and attention to detail.
• Ability to manage multiple tasks and deadlines effectively.
• Interpersonal skills, including ability to interface with providers and
medical office staff.
• Ability to work in a cross-functional highly matrixed organization.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Experience in provider services, operations, and/or contract negotiations in a
Medicaid, Medicare, and/or Marketplace managed health care setting - ideally
with different provider types (i.e. physician, group, hospital).

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