JOB DESCRIPTION
Job Summary
Molina Health Plan Operational Leadership roles provide overall direction and administration of the Plan's operational departments, programs, and services.
Responsibilities include implementing programs that are in alignment with Molina Healthcare's strategic and operating plan; providing day-to-day leadership and management of the health plan market or product operations that mirrors the company's mission, vision, and core values; and ensuring the efficient and compliant operations of the market or product of the health plan.
KNOWLEDGE/SKILLS/ABILITIES
Plans, organizes, staffs, and leads all activities of the State Plan's Provider Network Management and Operations Department. Works with staff and senior management to develop and implement provider contracting and service strategies to contain unit cost, improve member access and enhance provider satisfaction with the Plan. Also oversees provider credentialing, delegation oversight and provider network administration activities. Primary plan liaison for Claims, Member Services and other Corporate Departments.
- Develops and implements provider network and contract strategies, identifying those 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 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. Obtains input from Corporate and Legal regarding new reimbursement models.
- Develops and maintains a system to track contract negotiation activity on an ongoing basis throughout the year; utilize and oversees departmental training on Molina's contract management system.
- Directs the preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company templates and guidelines with physicians, hospitals, and other health care providers.
- Contributes as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization.
- Oversees the maintenance of all provider contract information and templates and ensures that all negotiated contracts can be configured in the QNXT system. Works with Legal and Corporate as needed to modify 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 Association(s) and Joint Operating Committee Management. May also have responsibility for provider problem research, resolution, and prevention.
- Provides accountability for Delegation Oversight function in the Plan.
- Provides oversight of the Provider Network Administration area to ensure accuracy of provider information in support of accurate configuration for claims payment.
JOB QUALIFICATIONS
Required Education
Bachelor's Degree in Business, Health Services Administration, or related field.
Required Experience
- 10+ years progressive experience in Healthcare Administration, Managed Care and/or Provider Services.
- Experience managing employees.
- Demonstrated adaptability and flexibility to changes and response to new ideas and approaches.
- Superior interpretation and research skills to readily identify problems, get to the root cause, and achieve prompt resolution to problems and issues including analytical skills.
Preferred Education
Master's Degree in Business, Health Administration, or related field.
Preferred Experience
Experience with Medicaid and Medicare managed care plans.
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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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