Director, Provider Network Management & Operations

Molina Healthcare • United States, United States • 1d ago

Remote and must live in the United States

JOB DESCRIPTION

Job Summary

Leads and directs team responsible for network operations and contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Also responsible for negotiating complex contracts that are strategically critical to plan/product success, including but not limited to: alternative payment models (APMs), value-based payment (VBP) contracts and capitated payments for hospitals, independent physician associations (IPAs), and complex behavioral health arrangements. Establishes and maintains a distinct high-performing and adequate network of compassionate and culturally sensitive providers aligned with Molina's mission, vision and values.

Essential Job Duties

Develops and implements provider network and contracting strategies; identifies specialties and geographic locations to concentrate resources for the purpose of establishing a sufficient network of participating providers to serve the health care needs of the plan's membership.

Develops and maintains a market-specific provider reimbursement strategy consistent with reimbursement tolerance parameters (across multiple specialties/geographies); oversees the development of new reimbursement models, collaborating with Molina corporate and legal departments.

Develops and maintains a system to track contract negotiation activity on an ongoing basis; utilizes and oversees departmental training on the contract management system.

Directs the preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company templates and guidelines related to contracting with physicians, hospitals, and other health care providers.

Contributes as a key member of the senior leadership team and other committees responsible to address the strategic goals of the department and organization.

Oversees the maintenance of all provider contract information, provider contract templates and ensures that all contracts negotiated can be configured in the QNXT system; collaborates with legal and corporate on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.

Oversees plan-specific fee schedule management.

Develops strategies to improve EDI/MASS rates.

Provides oversight of provider services and coordinates activities with provider associations and joint operating committees (JOCs).

Provides accountability for delegation oversight function in the plan.

Provides oversight of the provider network administration area including: provider information management, and business analyses of contracts and benefits to support accurate configuration for claims payment.

Oversees all provider/member issue prevention, research and resolution and provides oversight of the provider/member appeals and grievance process.

Coordinates with enrollment growth to ensure that Molina grows faster (profitable growth) than competitors in key provider practices.

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 experience in health care to include experience in provider network management/contracting, health care operations, and/or government-sponsored programs, and at least 6 years of senior level network operations experience, or equivalent combination of relevant education and experience.

At least 3 years of management/leadership experience.

Extensive experience in the health insurance industry.

Track record of strong relationships with hospitals, provider groups, and independent physician associations (IPAs).

Knowledge of reimbursement methodologies across all lines of business (Medicaid, Medicare, Marketplace).

Strong experience with various managed health care provider compensation methodologies.

Excellent negotiation and relationship building capabilities.

Ability to navigate complex regulatory environments.

Strong data-driven decision-making skills, and analytical abilities.

Strong organizational skills and attention to detail.

Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization, and influence business decisions.

Ability to manage multiple tasks and deadlines effectively.

Strong project management skills.

Excellent verbal and written communication skills, and ability to present at an executive level.

Microsoft Office suite and applicable software programs proficiency.

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

Pay Range: $87,568.7 - $189,732.18 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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