Provider Relations Manager

2 weeks ago


Springfield, Illinois, United States Molina Healthcare Full time
Job Overview

***Remote position; candidates must reside in Illinois***

Position Summary

The Provider Relations Manager at Molina Healthcare plays a crucial role in network expansion, ensuring network sufficiency, and facilitating provider education and training. This position aligns with Molina Healthcare's mission, core values, and strategic objectives while adhering to all relevant regulations at the federal, state, and local levels. The Provider Relations team serves as the primary liaison between Molina Healthcare and its network of contracted providers. Collaborating with the Director, this role manages and coordinates the Provider Services operations for the state health plan, working closely with management and staff to create and execute standardized provider service and relationship management strategies.

Key Responsibilities

The Provider Relations Manager will:

  • Oversee the Provider Relations functions and lead team members, ensuring efficient daily operations in collaboration with other departments and stakeholders.
  • In partnership with the Director of Provider Network Management & Operations, formulate health plan-specific provider contracting strategies, focusing on specialties and geographic areas to build a robust network of Participating Providers.
  • Guide the external provider representatives, developing and presenting policies, procedures, training materials, and reports to meet both internal and external standards.
  • Manage the Provider Service staff, including recruitment, training, and performance evaluation.
  • Support ongoing network development and educate contracted providers on plan procedures and claims payment policies.
  • Create and implement tracking systems to ensure timely resolution of issues and compliance with applicable standards.
  • Facilitate effective communication and intervention when providers encounter issues or complaints related to claims, eligibility, reimbursement, or website access.
  • Act as a resource to support the Plan's initiatives, ensuring regulatory compliance and alignment with strategic goals.
  • Enhance cross-departmental communication regarding Provider Services initiatives and provider network concerns.
  • Design and execute programs that foster positive relationships between contracted providers, ancillary providers, and hospital facilities.
  • Develop strategies to boost provider participation in HEDIS and quality improvement initiatives.
  • Engage with contracted providers on cost control measures, Medical Care Ratio (MCR), non-emergent utilization, and CAHPS to positively impact future trends.
  • Implement strategies aimed at reducing member access grievances with contracted providers.
  • Oversee the IHH program, ensuring alignment with departmental requirements, provider education, and overall management.

Qualifications

Required Education:

Bachelor's Degree in a Health or Business-related field or equivalent experience.

Required Experience/Knowledge, Skills & Abilities:

  • 5-7 years of experience in servicing physicians, hospitals, integrated delivery systems, and ancillary providers within Medicaid and/or Medicare frameworks.
  • 5+ years of prior experience in managed healthcare.
  • Experience collaborating with community agencies and providers.
  • Familiarity with various managed healthcare provider compensation methodologies, including fee-for-service, value-based contracts, capitation, and risk agreements.
  • Experience in preparing and delivering formal presentations.
  • 2+ years in a leadership role, either direct or matrix.
  • A minimum of 2 years of experience in managing or supervising employees.

Preferred Education:

Master's Degree in a Health or Business-related field.

Preferred Experience:

5-7 years of experience in managed healthcare administration, with specific expertise in provider services, operations, and contract negotiations in a Medicare and Medicaid environment.

Molina Healthcare provides a competitive benefits and compensation package and is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $59, $129,589.63 / ANNUAL
*Actual compensation may vary based on geographic location, work experience, education, and/or skill level.



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