Provider Relations Representative - Quality

Remote and must live in Wisconsin

Job Description

Job Summary

Molina Health Plan Network Provider Relations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Relations staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access / availability and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.

Job Duties

Provides information and resources internally, to providers, and to the general public regarding contracting processes, policies and procedures.

Oversight of the provider concern process for the MCO and ensures inquiries from providers and others receive timely and accurate responses.

Maintains, reviews, and responds to Provider Quality Concerns. Conducts provider visits when severe quality concerns are identified.

Assists the Provider Quality Lead Supervisor to identify trends and establish processes to address deficiencies or areas for improvement in all aspects of placement and provider concerns.

Works collaboratively with the Residential Team, Provider Network and Relations team and Care Management staff of My Choice Wisconsin in communicating provider updates and decisions to various stakeholders.

Conducts AFH certifications, tracks renewals, serves as a content expert for providers and PQ staff.

Assists the development of new network providers, including determining training needs and developing appropriate, timely technical support materials for incoming providers.

Researches and understands contracts, Wisconsin State Administrative Code and resolve issues in a timely manner.

Compiles and maintains information from the Department of Health Services and Statements of Deficiencies for contracted providers, following up with identified providers as needed.

Leads Provider Quality Advisory Work Group Meetings with the provider network.

Partners with Provider Quality Lead Supervisor to send and analyze the annual provider survey. Summarizes results and leads internal meetings to meet DHS requirements on identified initiatives from the survey results.

Assists with organization of the Provider Quality Newsletter.

Role requires 30% same-day or overnight travel. (Extent of same-day or overnight travel will depend on the specific Health Plan and its service area.)

Job Qualifications

REQUIRED EDUCATION :

Associate's Degree or equivalent provider contract, network development and management, or project management experience in a managed healthcare setting.

REQUIRED EXPERIENCE / KNOWLEDGE, SKILLS & ABILITIES :

• 2 - 3 years customer service, provider service, or claims experience in a managed care setting.
• Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to, fee-for service, capitation and various forms of risk, ASO, etc.

PREFERRED EDUCATION :

Bachelor’s Degree in a related field or an equivalent combination of education and experience

PREFERRED EXPERIENCE :

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.

PJCorp

Pay Range : $19.84 - $38.69 / HOURLY

Salary : $20 - $39