About the position
Molina's Provider Contracting function provides guidance, signature support services, standards and resources to help Molina Healthcare successfully establish and maintain distinct high performing networks of compassionate and culturally sensitive providers who: • Are aligned with our mission to provide quality health services to financially vulnerable families and individuals covered by government programs; • Help meet or exceed applicable access criteria and adequacy standards for covered services; • Agree to sign standard provider services agreements approved by applicable state/federal agencies and built on Molina's business standards that include sustainable value-based reimbursements; and • Are committed to providing quality healthcare for low income Members in an efficient and caring manner. Under the leadership of the AVP, Provider Network Management & Operations, oversees development and implementation of provider network and contract strategies, identifying those specialties and geographic locations upon which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of Molina membership.
Responsibilities
- Develops and maintains a standard provider reimbursement strategy consistent with reimbursement tolerance parameters (across multiple specialties/geographies).
- Obtains input from Corporate, Legal and other stakeholders regarding new reimbursement models and oversees their development.
- Develops and maintains a system to track contract negotiation activity on an ongoing basis throughout the year.
- Utilizes and oversees departmental training on the enterprise contract management system (Emptoris).
- Directs the preparation 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 department's leadership team and participates in committees addressing the department's strategic goals and organization.
- Oversees the maintenance of all provider contract information and provider contract templates.
- Ensures that contracts can be configured within the QNXT system.
- Works with Legal, Corporate and other stakeholders as needed to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.
- Monitors and reports network adequacy for Medicare and Medicaid services.
- Develops strategies to improve EDI/MASS rates.
- Educates and works with assigned state Health Plans on any corporate changes or initiatives as necessary.
- Works with assigned national vendors to improve contractual terms and maintain positive relationships.
- Provides national contracts support for other Molina departments/functions.
- Coordinates with Corporate and Business Development teams to ensure that Molina grows faster (profitable growth) than our competitors in target new markets and expansion opportunities.
- Provides training and guidance as needed to the Contract Managers and Contract Specialist(s).
- Helps develop and utilize standardized contract templates and Pay for Performance strategies.
- Utilizes sound reporting and analytical tools to develop and refine strategic work plans.
Requirements
- Bachelor's Degree in a related field (Business Administration, etc.) or equivalent experience.
- 7 - 10 years minimum experience in Healthcare Administration, Managed Care, and/or Provider Network Mgmt & Operations with an emphasis on value based provider contracting.
Nice-to-haves
- Master's Degree.
- 3-5 years minimum experience in contracting with hospitals, physician groups, high volume specialists and ancillary providers.
Benefits
- Competitive benefits and compensation package.
