AVP, Network Strategy & Services - Indiana

Molina Healthcare•Long Beach, CA

37d

About The Position

Provides strategy and leadership to team responsible for provider network management, operations, and contracting activities . Leads network strategy and development with respect to adequacy, financial performance, and operational performance. Develops network standards and resources designed to enable Molina to establish and maintain distinct high-performing networks of compassionate and culturally sensitive providers aligned with Molina's mission, vision and values.

Requirements

At least 10 years of experience in health care to include experience in provider network management/contracting, health care operations, and/or government-sponsored programs, and at least 8 years of senior level network operations experience, or equivalent combination of relevant education and experience.
At least 5 years of management/leadership experience.
Extensive experience in the health insurance industry.
Track record of strong relationships with hospitals, provider groups, and independent physician associations (IPAs).
Expert level knowledge regarding reimbursement methodologies across all lines of business (Medicaid, Medicare, Marketplace).
Strong experience with various managed health care provider compensation methodologies.
Excellent negotiation and relationship building capabilities.
Ability to navigate complex regulatory environments.
Strong data-driven decision-making skills, and analytical abilities.
Strong organizational skills and attention to detail.
Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization, and influence business decisions.
Ability to manage multiple tasks and deadlines effectively.
Strong project management skills.
Excellent verbal and written communication skills, and ability to present at an executive level.
Microsoft Office suite and applicable software programs proficiency.

Responsibilities

Supports strategy development, vision and direction for the network function. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
Develops and implements provider network and contract strategies in new Molina markets - 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 Molina's membership and meet established financial goals.
Develops and maintains a market-specific provider reimbursement strategies consistent with reimbursement tolerance parameters (across multiple specialties/geographies).
Oversees the development of new reimbursement models; facilitates communication, oversight and approval processes for health plan exceptions for all lines of business.
Develops and enhances the provider network management and operations function including the implementation of standard processes, policies and procedures.
Develops a standardized provider engagement “tool kit”, training program and deployment plan.; develops and implements approaches to determining outcomes of tools and training programs.
Collaborates closely with health plans leadership to ensure compliance with all Molina, regulatory and industry standards.
Supports and executes new health plan implementations, acquisitions and expansions in collaboration with the business development team.
Collaborates with senior leadership, health plan leadership, and collaborating functions to develop and implement provider contracting strategies and provider service strategies to contain unit cost, improve member access and enhance provider satisfaction enterprise-wide.
Develops and oversees deployment strategy and monitoring for “provider profiles” and “pay-for-performance (P4P)” contracting.
In conjunction with provider services and provider contracting leaders in the health plans and within the corporate function, develops and implements approaches for performance management of value-based reimbursement.
Develops and refines “clear coverage” provider adoption strategies and assists in training of health plan staff as clear coverage is implemented in each plan.
Represents provider engagement with stakeholder experience, quality and RAMP business partners to ensure incorporate of necessary plans to achieve positive operational and financial outcomes.
Develops and maintains a system to track contract negotiation activities; facilitates health plan implementation, utilization, compliance, and develops and delivers enterprise-wide training for the contract management system.
Develops and authors all enterprise contract templates in conjunction with legal; disseminates templates, and maintains and updates to include state regulatory changes, operational business objectives and financial terms; maintains language libraries for the enterprise.
Directs the strategy, preparation and negotiations of national provider contracts across the enterprise; oversees negotiation of national contracts in concert with established company templates and guidelines with vendors, physicians, hospitals, and other health care providers.
Monitors key metrics to determine provider engagement effectiveness and success (e.g. provider appeals and grievances, member appeals and grievances, Consumer Assessment of Healthcare Providers and Systems (CAHPs), STAR ratings, Healthcare Effectiveness Data Information Set (HEDIS), HEP completion Rates, etc.)
Leads and manages the development and implementation of activities for network development and contracting projects.
Directs the evaluation, review, and negotiation processes for network development projects.
Supports business development and new business implementation engagements across markets, taking into consideration individual market circumstances, provider community, budget guidelines and available resources.
Completes negotiations with complex and major provider contracts as needed to support network objectives.
Leads the network development and contracting teams during the development and implementation stages.
Monitors performance in accordance with Molina standards and guidelines; communicates with senior leadership and other Molina leaders regarding network strategy and planning.
Contributes as a key member of the corporate network leadership team.
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.
Develops and sustains a high-performance team, dedicated to best in class solutions; responsible for attracting, developing and retaining top-tier talent to support strategy and long-term business objectives.