Manager, Health Plan Provider Contracts

Molina Healthcare, Inc.; United States; On-site; USD 120,000 - 170,000; Full time

Job summary

Molina Healthcare, Inc. is seeking a lead for the provider network contracting function to negotiate and manage complex agreements with hospitals, IPAs, and large specialty groups.

The role supports network strategy, adequacy, financial and operational performance to drive plan success. The position focuses on alternative payment models (APMs), value-based contracts and capitated payments while improving MCR and regional savings through recontracting initiatives.

Qualifications

• 7+ years in network contracting with large multispecialty provider groups
• 4+ years in provider contract negotiations in managed care
• Experience with Medicaid/Medicare value-based payment, capitation and risk models
• Strong negotiation and relationship-building capabilities
• Ability to navigate complex regulatory environments
• Excellent organization and attention to detail

Responsibilities

• Oversee provider contracting function and coordinate with other departments
• Negotiate complex contracts with large providers to ensure high quality and cost-effectiveness
• Manage contracts/re-contracts with large-scale entities requiring custom reimbursement
• Develop and execute APM/VBP contracts and standard reimbursement models
• Monitor network adequacy and compliance with regulatory requirements
• Educate internal stakeholders on provider contracts and participate in strategic committees

Skills

Negotiation

Leadership

Regulatory navigation

Data analysis

Cross-functional collaboration

Time management

Communication

Tools

MS Office

Job description

Job Summary

Leads and manages team responsible for health plan provider network contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Responsible for negotiating complex contracts that are strategically critical to plan success, including but not limited to: alternative payment models (APMs), value-based payment (VBP) contracts and capitated payments for hospitals, independent physician associations (IPAs), and complex behavioral health arrangements.

Essential Job Duties

• Oversees the plan’s provider contracting function; collaborates with other operational departments and functional business unit stakeholders on various provider contracting activities.
• Negotiates contracts with the complex provider community that result in high quality, cost-effective and marketable providers.
• Contracts/re-contracts with large-scale entities involving custom reimbursement.
• Executes standardizedalternative payment model (APM) or value-based payment (VBP) contracts.
• Issues escalations and supports network adequacy, joint operating committees (JOCs), and delegation oversight.
• In conjunction with contracting leadership, develops health plan-specific provider contracting strategies including VBP; includes identifying specialties and geographic locations to concentrate resources for the purpose of establishing a sufficient network of participating providers to serve the health care needs of the plan’s members, in addition to identifying VBP provider targets to meet Molina goals.
• Assists in achieving annual savings through recontracting initiatives; implements cost-control initiatives to positively influence the medical cost ratio (MCR) in each contracted region.
• Prepares the provider contracts in concert with established company guidelines with physicians, hospitals, managed long-term services and supports (MLTSS) and other health care providers.
• Utilizes established reimbursement tolerance parameters (across multiple specialties/ geographies), and oversees the development of new reimbursement models.
• Oversees the maintenance of all provider and payer contract templates; collaborates with legal and corporate network management on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.
• Ensures compliance with applicable provider panel and network capacity, adequacy requirements and guidelines; produces and monitors weekly/monthly reports to track and monitor compliance with network adequacy requirements.
• Develops and implements strategies to minimize the company’s financial exposure; monitors and adjusts strategy implementation as needed to achieve desire goals and reduce minimize the company’s financial exposure.
• Advises network provider contract specialists on negotiation of individual provider and routine ancillary contracts.
• 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 corporate attorney.
• Participates in fee schedule determinations including development of new reimbursement models; seeks input on new reimbursement models from corporate network management, legal and senior level engagement as required.
• Educates internal customers on provider contracts.
• Participates on the management team and other committees addressing the strategic goals of the department and organization.
• 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 7 years of experience in network contracting with large specialty or multispecialty provider groups, and at least 4 years experience in provider contract negotiations in a managed health care setting ideally negotiating different provider contract types (i.e. physician/group/hospital), or equivalent combination of relevant education and experience.
• At least 1 year of management/leadership experience.
• Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: value-based payment (VBP), fee-for service (FFS), capitation and various forms of risk, etc.
• Strong negotiation and relationship building capabilities.
• Ability to navigate complex regulatory environments.
• Strong organizational skills and attention to detail.
• Data-driven decision-making skills, and analytical abilities.
• Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization.
• Strong ability to manage multiple tasks and deadlines effectively.
• Strong verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Experience negotiating alternative payment models (APMs).
• Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.

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