AddressDescription
Remote and must live in Illinois
Job Description:
Job Summary
Molina Health Plan Network Provider Relations 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.
They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.
Job Duties- Under general supervision, works directly with the Plan's external complex 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.
- Resolves complex provider issues that may cross departmental lines including Contracting, Finance, Quality, Operations, and involve Senior Leadership.
- Responsible for Provider Satisfaction survey results.
- Develops and deploys strategic network planning tools to drive Provider Relations and Contracting Strategy across the enterprise.
- Facilitates strategic planning and documentation of network management standards and processes. Effectiveness is tied to financial and quality indicators.
- Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practices sharing across the organization.
- MCST matrix team environmental support including, but not limited to: New Markets Provider/Contract Support Services, PCRP & CSST resolution support, and National Contract Management support services.
- 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, noncompliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the nonclinical quality of customer service provided to Molina members.
- Provides onthespot 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 problemsolving meetings between the provider and Molina stakeholders, including senior leadership and physicians. For example, such meetings would occur to discuss and resolve 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 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 Relations Representatives as appropriate.
- Role requires 60%+ sameday or overnight travel. (Extent of sameday or overnight travel will depend on the specific Health Plan and its service area.)
REQUIRED EDUCATION:
Bachelor's Degree in a healthcare related field or an equivalent combination of education and experience.
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
- 46 years provider contract network relations and management experience in a managed healthcare setting.
- Working experience servicing complex providers with various managed healthcare provider compensation methodologies, including but not limited to: feefor service, valuebased contracts, capitation and vario
