Job Description ***Remote and must live in Kentucky*** Job Description Job Summary
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.
Responsible for contracting/re-contracting of Complex contracts with Alternative Payment Methods including but not limited to Value Based and Capitated payments for Hospitals, Independent Practice Associations, and complex Behavioral Health arrangements.
Maintains network adequacy, issue escalations and JOCs.
Entail heavy negotiations.
Maintains critical Complex provider information on claims and provider databases. Synchronizes data among multiple claims systems and application of business rules as they apply to each database.
Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing.
Job Duties
Manages the Plan's Provider Contracting functions and team members. Responsible for the daily operations of the department working collaboratively with other operational departments and functional business unit stakeholders to lead or support various Provider Contracting functions. This role negotiates contracts with the Complex Provider Community that result in high quality, cost effective and marketable providers. Contract/Re-contracting with large scale entities involving custom reimbursement. Executes standardized Alternative Payment Method or Value Based Payment (VBP) contracts. Issue escalations, network adequacy, Joint Operating Committees, and delegation oversight.
•In conjunction with Director, Provider Contracts, develops health plan-specific provider contracting strategies including VBP. This includes identifying specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of the Plan's patients or members, in addition to identifying VBP provider targets to meet Molina goals.
•Assists in achieving annual savings through recontracting initiatives. Implements cost control initiatives to positively influence the Medical Care Ratio (MCR) in each contracted region.
•Prepares the provider contracts in concert with established company guidelines with physicians, hospitals, MLTSS and other health care providers.
•Utilizes established Reimbursement Tolerance Parameters (across multiple specialties/ geographies). Oversees the development of new reimbursement models in concert with Director.
•Oversees the maintenance of all Provider and payer Contract Templates. Works with legal and Corporate Network Management on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.
•Ensures compliance with applicable provider panel and network capacity, adequacy requirements and guidelines. Produces and monitors weekly/monthly reports to track and monitor compliance with network adequacy requirements.
•Develops and implements strategies to minimize the company's financial exposure. Monitors and adjusts strategy implementation as needed to achieve desire goals and reduce minimize the company's financial exposure.
•Advises Network Provider Contract Specialists on negotiation of individual provider and routine ancillary contracts.
•Evaluates provider network and implement strategic plans with the goal of meeting Molina's network adequacy standards.
•Assesses contract language for compliance with Corporate standards and regulatory requirements and review revised language with assigned MHI attorney.
•Participates in fee schedule determinations including development of new reimbursement models. Seeks input on new reimbursement models from Corporate Network Management, legal and VP level engagement as required.
•Educates internal customers on provider contracts.
•Participates on the management team and other committees addressing the strategic goals of the department and organization.
•Manages and provides coaching to Network Contracts Staff.
•Manages and evaluates team member performance; provides coaching, consultation, employee development, and recognition; ensures ongoing, appropriate staff training; holds regular team meetings to drive good communication and collaboration; and has responsibility for the selection, orientation and mentoring of new staff.
Job Qualifications REQUIRED EDUCATION:
Bachelor's Degree in a related field (Business Administration, etc.,) or equivalent experience
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
•5-7 years experience in Healthcare Administration, Managed Care, Provider Contracting and/or Provider Services, including 2+ years in a direct or matrix leadership position
•3+ 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.
•Working experience 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.
•Min. 2 years experience managing/supervising employees.
PREFERRED EDUCATION:
Master's Degree in a related field or an equivalent combination of education and experience
PREFERRED EXPERIENCE:
Experience Negotiating Alternative Payment Methods
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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