Molina Health Plan Provider Network Management and Operations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Services staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for the provider training, network management and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.
This role serves as the primary point of contact between Molina Health plan and the Provider community that serves Molina members. It's an external-facing, field-based position requiring a high degree of job knowledge, communication and organizational skills to successfully engage high volume, high visibility providers (including senior leaders and physicians) to ensure provider satisfaction, education on key Molina initiatives, and improved coordination and partnership.
• Under minimal direction, works 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.
• Conducts regular provider site visits within assigned region/service area. Determines own daily or weekly schedule, as needed to meet or exceed the Plan's monthly site visit goals. A key responsibility of the Representative during these visits is to proactively engage with the provider and staff to determine, for example, non-compliance with Molina policies/procedures or 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, which may include counseling providers diplomatically, while retaining a positive working relationship.
• Independently troubleshoots problems as they arise, making an assessment when escalation to a Senior Representative, Supervisor, or another Molina department is needed. 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. Such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding, for example.
• 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 JOC's).
• 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 - CAHPS, regulatory-related, Molina Quality programs, and taking advantage of electronic solutions (EDI, EFT, EMR, Provider Portal, Provider Website, etc.).
• Trains other Provider Services Representatives as appropriate.
• Role requires 80%+ same-day or overnight travel. (Extent of overnight travel will depend on the specific Health Plan and its service area.)
Bachelor's Degree or equivalent provider contract, network development and management, or project management experience in a managed healthcare setting.
• 2 - 3 years customer service, provider service, or claims experience in a managed care setting.
• Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to, fee-for service, capitation and various forms of risk, ASO, etc.
• 5 years experience in managed healthcare administration and/or Provider Services.
• 5 years experience in provider contract negotiations in a managed healthcare setting ideally in negotiating different provider contract types, i.e. physician, group and hospital contracting, etc.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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