Senior Representative, Health Plan Provider Relations & Contracting (Michigan)

Molina Healthcare; Dearborn (MI); On-site; USD 50,000 - 97,000; Full time

Job summary

Molina Healthcare in Michigan is seeking an experienced Provider Relations Specialist to support network development, education, and member access. You will serve as the primary contact between Molina and contracted providers, ensuring adherence to policies and high-quality service across Medicare and Medicaid lines.

Responsibilities include engaging high-priority providers, conducting site visits, delivering trainings, resolving complex issues, and coordinating with senior leadership to

Qualifications

• At least 3 years of customer service, provider services, or claims experience in a managed care or medical office setting.
• Understanding of the health care delivery system, including government-sponsored health plans.
• Understanding of provider compensation methodologies (FFS, capitation, risk).
• Experience delivering training and facilitating educational presentations.

Responsibilities

• Engages high-priority, high-volume providers to improve satisfaction and education on Molina initiatives.
• Acts as primary contact between Molina and contracted providers within the network.
• Educates providers on Molina policies, CMS guidelines, and compliance requirements; drives issue resolution and portal adoption.
• Resolves complex provider issues that cross departments and involve senior leadership when needed.
• Conducts provider site visits; plans schedule to meet monthly goals and assesses non-clinical service quality.

Skills

Customer service

Provider services

Communication

Training delivery

Cross-functional collaboration

Tools

Microsoft Office

Job description

JOB DESCRIPTION

*Employee for this role must reside in Michigan

Job Summary

Provides senior level support 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.

Essential Job Duties

• Successfully engages the plan's highest priority, high-volume and strategic complex community providers to ensure provider satisfaction, facilitate education on key Molina initiatives, and improve coordination and partnership between the health plan and contracted providers.
• Serves as the primary point of contact between Molina health plan and the complex provider community that services Molina members, including but not limited to fee-for-service (FFS) and pay-for-performance (P4P) providers.
• Collaborates directly with the plan’s external providers to educate, advocate and engage as valuable partners - ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service; effectively drives timely issue resolution, electronic medical record (EMR) connectivity, and provider portal adoption.
• Resolves complex provider issues that may cross departmental lines and involve senior leadership.
• Conducts regular provider site visits within assigned region/service area; determines daily or weekly schedule, to meet or exceed the plan's monthly site visit goals. Proactively engages with the provider and staff to determine; for example, non-compliance with Molina policies/procedures or Centers for Medicare and Medicaid Services (CMS) guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members.
• Provides on-the-spot training and education as needed, including counseling providers diplomatically, while retaining a positive working relationship.
• Independently troubleshoots provider problems as they arise, and takes initiative in preventing and resolving issues between the provider and the plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters.
• Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians (examples include: issues related to utilization management, pharmacy, quality of care, and correct coding).
• Independently delivers training and presentations to assigned providers and their staff - answering questions that come up on behalf of the health plan; may also deliver training and presentations to larger groups, such as leaders and management of provider offices, including large multispecialty groups or health systems, executive level decision makers, association meetings, and joint operating committees (JOCs).
• Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives; examples of such initiatives include: administrative cost-effectiveness, member satisfaction - Consumer Assessment of Healthcare Providers and Systems (CAHPS), regulatory-related, Molina quality programs, and taking advantage of electronic solutions (electronic data interchange (EDI), EMR, provider portal, provider website, etc.).
• Serves as a subject matter expert for the provider relations function.
• Provides training and support to new and existing provider relations team members.
• Role requires team meeting travel once per quarter in the state of Michigan.

Required Qualifications

• At least 3 years of customer service, provider services, or claims experience in a managed care or medical office setting, or equivalent combination of relevant education and experience.
• Understanding of the health care delivery system, including government-sponsored health plans.
• Understanding of 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.
• Experience delivering training and facilitating educational presentations.
• Organizational skills and attention to detail.
• Ability to manage multiple tasks and deadlines effectively.
• Interpersonal skills, including ability to interface with providers and medical office staff.
• Ability to work in a cross-functional highly matrixed organization.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Experience in provider services, operations, and/or contract negotiations in a Medicaid, Medicare, and/or Marketplace managed health care setting - ideally with different provider types (i.e. physician, group, hospital).

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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

Pay Range: $49,930 - $97,363 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.