Job Description
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. Negotiates agreements with Complex providers who are strategic to the success of the Plan, including but not limited to, Hospitals, Independent Physician Association, and complex Behavioral Health arrangements.
Job Duties
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 contracts. Issue escalations, network adequacy, Joint Operating Committees, and delegation oversight. Tighter knit proximity ongoing after contract.
• In conjunction with Director/Manager, Provider Contracts, negotiates Complex Provider contracts including but not limited to high priority physician group and facility contracts using Preferred, Acceptable, Discouraged, Unacceptable (PADU) guidelines. Emphasis on number or percentage of Membership in Value Based Relationship Contracts.
• Develops and maintains provider contracts in contract management software.
• Targets and recruits additional providers to reduce member access grievances.
• Engages targeted contracted providers in renegotiation of rates and/or language. Assists with cost control strategies that positively impact the Medical Care Ratio (MCR) within each region.
• Advises Network Provider Contract Specialists on negotiation of individual provider and routine ancillary contracts.
• Maintains contractual relationships with significant/highly visible providers.
• 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.
• Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital and ancillary providers.
• Participates with the management team and other committees addressing the strategic goals of the department and organization.
• Participates in other contracting related special projects as directed.
• Travels regularly throughout designated regions to meet targeted needs
Job Qualifications
REQUIRED EDUCATION:
Bachelor’s Degree in a healthcare related field or an equivalent combination of education and experience.
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
• 5-7 years contract-related experience in the health care field including, but not limited to, provider’s office, managed care organization, or other health care environment.
• 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 familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: Value Based Payment, fee-for service, capitation and various forms of risk, ASO, etc.
PREFERRED EDUCATION:
Master's Degree in a related field or an equivalent combination of education and experience
PREFERRED EXPERIENCE:
3 years in Provider Network contracting
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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Job Info
Job Identification: 2029017
Job Category: Network Management
Posting Date: 2024-11-13T20:44:29 00:00
Job Schedule: Full time
