Director, Health Plan Provider Relations - Remote in Boise, ID

Molina Healthcare; Boise (ID); Remote; USD 110,000 - 150,000; Full time

Job summary

Molina Healthcare in Boise, Idaho seeks a senior leader to guide provider relations, directing a team responsible for education, outreach, and issue resolution to strengthen network performance.

The role collaborates with network management to shape strategies, develop standardized tools, and ensure adherence to plan procedures and regulatory requirements across the organization.

Qualifications

• At least 8 years of provider services experience across providers, facilities and health plans.
• At least 3 years of management/leadership experience.
• Strong understanding of the health care delivery system and government-sponsored plans.
• Experience with provider relations, education and contract services.

Responsibilities

• Oversees provider relations function and team operations, directing education, outreach and issue resolution.
• Develops network strategies to build and sustain a sufficient provider network for plan members.
• Leads cross-functional initiatives with network management to share standards, tools and best practices.
• Develops planning tools and processes for network management across lines of business.
• Builds training programs and ensures compliance with Molina policies and procedures.

Skills

Provider relations

Team leadership

Healthcare delivery knowledge

Regulatory compliance

Tools

Contract management

Job description

Job Summary

Leads and directs team responsible for health plan provider relations activities. Supports network development, network adequacy and provider training and education. Serves as primary point of contact between the business and contracted providers within the Molina network. Responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina policies and procedures. Collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services for the health plan.

Essential Job Duties

• Oversees the plan's provider relations function and team members. Responsible for the daily operations of the department, including leading and supporting various provider relations activities including provider education, outreach and inquiry resolution.
• Develops health plan-specific provider relations strategies - identifying specialties and geographic locations to concentrate resources for the purposes of establishing a sufficient network of participating providers to serve the health care needs of the plan's members, and successfully develop and refine cost-effective and high-quality strategic provider networks - ensuring establishment of both internal and external long-term partnerships.
• Collaborates with health plan network management and operations teams and functional business unit stakeholders to lead and/or support various provider services functions and strategic initiatives with an emphasis on developing and implementing standards, resources, tools and best practices sharing across the organization.
• Develops and deploys strategic network planning tools to drive provider services and contracting strategy across the organization. Facilitates planning and documentation of network management standards and processes for all lines of business.
• Provides matrix team support including but not limited to: new markets provider/contract support services, resolution support, and national contract management support services.
• Builds and/or facilitates provider communication, training and education programs for internal staff, external providers, and other stakeholders.
• Ensures compliance with applicable company/plan business requirements including state/federal statutes, government sponsored program requirements, and network access standards.
• Oversees and leads provider representatives activities, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards.
• Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claims payment policies.
• Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards related to provider relations.
• Oversees appropriate and timely interventions/communications when providers have issues or complaints (e.g., problems with claims and encounter data, eligibility, reimbursement, and provider website).
• Serves as a resource to support the plan's initiatives and helps to ensure regulatory requirements and strategic goals are realized.
• Ensures appropriate cross-departmental communication of provider relations initiatives and contracted network provider issues.
• Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and the plan.
• Develops and implements strategies to increase provider engagement in Healthcare Effectiveness Data Information Set (HEDIS) and quality initiatives.
• Engages contracted network providers regarding cost control initiatives, medical cost ratio (MCR), non-emergent utilization, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to positively influence future trends.
• Develops and implements strategies to reduce member access grievances with contracted providers.
• Oversees the integrated health home (IHH) program and ensures IHH program alignment with department requirements, provider education and oversight.
• Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration.

Required Qualifications

• At least 8 years of provider services experience, including experience supporting individual/group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid, Medicare, and or Marketplace products, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Strong understanding of the health care delivery system, including government-sponsored health plans.
• Experience with vari