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Senior Provider Relations Specialist
2 months ago
***Remote position; candidates must reside in Nebraska***
Position Summary
The Provider Relations team at Molina Healthcare plays a crucial role in network expansion, ensuring network sufficiency, and delivering training and education to providers. This position aligns with Molina Healthcare's mission and core values while adhering to all applicable federal, state, and local regulations. The Provider Relations Representatives serve as the primary liaison between Molina Healthcare and its contracted provider network, focusing on network management, provider education, communication, satisfaction, and compliance with Molina's policies and procedures, all while delivering exceptional customer service.
Key Responsibilities
This role acts as the main contact for Molina Health Plan, engaging with high-priority, high-volume, and strategically important non-complex providers that serve Molina members, including Fee-For-Service and Pay for Performance providers. It is an external-facing position that requires extensive knowledge of provider relations and contracting to effectively interact with key providers, including senior leaders and physicians, ensuring their satisfaction and understanding of Molina's initiatives.
• Operate under general supervision to educate and engage external providers, advocating for their needs while ensuring adherence to Molina's policies and procedures and maintaining high levels of customer service. Effectively resolve issues, facilitate EMR connectivity, and promote Provider Portal usage.
• Address complex provider issues that may involve multiple departments and require input from Senior Leadership.
• Serve as a subject matter expert for other departments within the organization.
• Conduct regular visits to provider sites within the designated region/service area, managing your schedule to meet or exceed monthly visit targets. Engage proactively with providers and their staff to identify non-compliance with Molina policies or CMS regulations and assess the quality of service provided to Molina members.
• Provide immediate training and education as necessary, maintaining a positive rapport with providers.
• Independently troubleshoot emerging issues, determining when to escalate matters to a Senior Representative, Supervisor, or another Molina department. Take proactive measures to prevent and resolve conflicts between providers and the Plan.
• Initiate and participate in problem-solving discussions with providers and Molina stakeholders, including senior leadership and physicians, to address issues related to utilization management, pharmacy, quality of care, and accurate coding.
• Deliver training and presentations to assigned providers and their staff, addressing questions on behalf of the Health Plan. May also conduct training for larger groups, including executive-level decision-makers and management from provider offices.
• Play a vital role in network management by monitoring compliance with company policies and enhancing provider effectiveness through education and promotion of Molina initiatives, such as administrative cost efficiency, member satisfaction, regulatory compliance, and the adoption of electronic solutions (EDI, EFT, EMR, Provider Portal, etc.).
• Train other Provider Relations Representatives as needed.
• This role requires significant travel, with over 40% of time spent on same-day or overnight trips, depending on the specific Health Plan and its service area.
Qualifications
Required Education:
Bachelor's Degree or equivalent experience in provider contracting, network development, or project management within a managed healthcare environment.
Required Experience/Knowledge, Skills & Abilities:
• 3 - 5 years of experience in customer service, provider services, or claims within a managed care context.
• 3+ years of experience in managed healthcare administration and/or Provider Services.
• Familiarity with various managed healthcare provider compensation models, particularly in Medicaid and Medicare, including fee-for-service, capitation, and risk-based arrangements.
Preferred Experience:
• 5+ years of experience in managed healthcare administration and/or Provider Services.
• 3+ years of experience in provider contract negotiations within a managed healthcare setting, ideally involving various types of provider contracts, such as those for physicians, groups, and hospitals.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $44, $97,362.61 / ANNUAL
*Actual compensation may vary based on geographic location, work experience, education, and/or skill level.
