Value-Based Provider Engagement Lead

Molina Healthcare; Louisville (KY); On-site; USD 63,000 - 115,000; Full time

Job summary

Molina Healthcare in Louisville, KY is seeking a Provider Engagement Specialist to lead health plan provider engagement strategies and improve quality and risk adjustment outcomes through data-driven coaching and collaboration with providers.

The role requires extensive experience in HEDIS quality scores, risk adjustment, and value-based care, with strong analytical and communication skills to drive performance across Medicaid, Medicare, and Marketplace programs.

Qualifications

• At least 6 years of experience improving population-level HEDIS quality scores and burden of illness documentation accuracy through provider engagement, or equivalent combination of relevant education and experience.
• Experience with various managed health care provider compensation methodologies including fee-for service (FFS), value-based care (VBC), and capitation.
• Strong working knowledge of quality metrics and risk adjustment practices across all business lines.
• Advanced knowledge and understanding of HEDIS/NCQA and/or CMS STARS quality measures and risk adjustment practices across Medicaid, Medicare, and Marketplace.
• Strong proficiency with data analysis, manipulation, interpretation, and reporting.
• Critical-thinking, problem-solving, and analytical skills.
• Attention to detail and organizational skills.
• Ability to implement process improvement initiatives and drive change.
• Ability to work independently in a fast-paced, deadline-driven environment.
• Ability to foster and build relationships in a cross-functional highly matrixed organization to obtain buy-in and drive results.
• Project management experience.
• Strong verbal and written communication skills.
• Microsoft Office suite (including Excel), Power BI, and other applicable software programs proficiency, and ability to learn new information systems and software programs.

Responsibilities

• Provides support for provider engagement activities including enhancing value-based strategies and risk adjustment/quality improvement initiatives.
• Ensures assigned Tier 1 providers have a provider engagement plan to meet annual quality and risk adjustment performance goals; may engage Tier 2 providers as needed.
• Drives provider partner coaching and collaboration to improve Medicaid, Medicare and Marketplace quality performance and risk adjustment accuracy through consistent provider meetings, action item development, and execution.
• Works with provider front-office staff to get the Molina members with the most open gaps on the schedule seen by their assigned provider. Coordinates with Health Plan Community and Member Engagement resources to drive supporting effort on the member side.
• Addresses challenges/barriers in the practice environment impending successful attainment of program goals and understands solutions required to improve health outcomes.
• Drives provider participation in Molina risk adjustment and quality efforts (e.g., supplemental data, electronic medical record (EMR) connection, clinical profiles programs) and use of the Molina provider collaboration portal.
• Mentors and assists Provider Engagement Specialists and Senior Specialists with training and problem escalation.
• Tracks all engagement and training activities using standard Molina provider engagement tools to measure effectiveness.
• Works collaboratively with health plans and shared service partners to ensure alignment to business goals.
• Accountable for use of standard Molina Provider Engagement reports and training materials.
• Develops, organizes, analyzes, documents, and implements processes and procedures as prescribed by health plan and corporate policies.
• Communicates comfortably and effectively with internal and external stakeholders, including physician leaders, providers, practice managers, and medical assistants within assigned provider practices.
• Provides training and support for new and existing practice transformation and provider engagement team members.
• Maintains the highest level of compliance.
• May require same day out-of-office travel up to 80% of the time, depending upon state/health plan requirements.

Skills

HEDIS quality improvement

Risk adjustment

Provider engagement

Data analysis

Communication

Project management

Microsoft Excel

Power BI

Cross-functional collaboration

Education

Bachelor’s degree in Nursing, Health Administration or relevant discipline

Tools

Power BI

Microsoft Excel

Job description

Molina Healthcare in Louisville, KY is seeking a Provider Engagement Specialist to lead health plan provider engagement strategies and improve quality and risk adjustment outcomes through data-driven coaching and collaboration with providers.

The role requires extensive experience in HEDIS quality scores, risk adjustment, and value-based care, with strong analytical and communication skills to drive performance across Medicaid, Medicare, and Marketplace programs.