Manager, Health Plan Provider Relations & Contracting

Molina Healthcare; Milwaukee (WI); On-site; USD 110,000 - 150,000; Full time

Job summary

Molina Healthcare in Wisconsin seeks an experienced Provider Relations Leader to guide a team and shape the provider network strategy within the Molina network. You will educate providers, coordinate outreach, and resolve issues in partnership with corporate network teams.

The role emphasizes strategic engagement with contracted providers across Medicaid, Medicare, and Marketplace products, ensuring regulatory compliance and high-quality service delivery.

Qualifications

• 7+ years of provider services experience including Medicaid, Medicare and Marketplace exposure.
• At least 1 year of management/leadership experience.
• Strong understanding of the healthcare delivery system and government-sponsored plans.
• Experience with provider compensation methodologies (FFS, capitation, risk, ASO).
• Experience presenting formal presentations and interfacing with providers.

Responsibilities

• Oversees the plan's provider relations function and team members, handling daily operations.
• Develops health plan-specific provider relations strategies with leadership to expand the network.
• Leads provider representatives activities, policies, training materials, and reports.
• Educates contracted providers on plan procedures and claims payment policies.
• Implements tracking tools to ensure timely issue resolution and compliance.
• Manages provider interactions for claims, eligibility, reimbursement, and website issues.
• Drives cross-departmental communication and regulatory alignment; supports strategic goals.

Skills

Provider services experience

Management leadership

Healthcare delivery knowledge

Communication skills

MS Office proficiency

Tools

Microsoft Office

Job description

Employee must reside in Wisconsin

Leads and manages team responsible for health plan provider relations activities. Supports network development, network adequacy, contracting, 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, internal and external escalations, 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, strategic initiatives, 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.
• In conjunction with provider network leadership, 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.
• 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.
• Additional duties as assigned

Required Qualifications

• At least 7 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 1 year of management/leadership experience.
• Strong understanding of the health care delivery system, including government-sponsored health plans.
• Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including: fee-for service (FFS), capitation and various forms of risk, ASO, etc.
• Previous experience with community agencies and providers.
• Strong organizational skills and attention to detail.
• Ability to manage multiple tasks and deadlines effectively.
• Experience with preparing and presenting formal presentations.
• Strong interpersonal skills, including ability to interface with providers and medical office staff.
• Ability to work in a cross-functional highly matrixed organization.
• Strong verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Contract negotiation experience
• Specific experience in provider services, operations, and/or contract negotiations in a Medicare and Medicaid managed healthcare setting, ideally with different provider types (e.g. physician, groups, hospitals, HCBS/waiver, Long Term C