Director, Health Plan Provider Relations (Provider Engagement - NY Based) - REMOTE

Molina Healthcare•Long Beach, NY

20h•Remote

About The Position

Leads and directs the team responsible for provider relations activities for the New York Health Plan. Supports network development, network adequacy, and provider training and education, and serves as the primary point of contact between the business and contracted providers in the Molina network. Oversees network management activities, including provider education, communication, satisfaction, issue intake, access and availability, and compliance with Molina policies and procedures. Collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services for the health plan. The role oversees the provider relations function and daily department operations, develops health plan-specific provider relations and network strategies, and supports provider services functions and strategic initiatives across the organization. It also leads provider communication and education, ensures compliance with applicable business and regulatory requirements, oversees issue resolution and provider representative activities, and manages team member hiring, training, coaching, development, and performance.

Requirements

At least 8 years of provider services experience, including support for individual and group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid, Medicare, and/or Marketplace products, or an equivalent combination of relevant education and experience.
At least 3 years of management or leadership experience.
Strong understanding of the health care delivery system, including government-sponsored health plans.
Experience with managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including fee-for-service, capitation, various forms of risk, and ASO.
Previous experience with community agencies and providers.
Strong organizational skills and attention to detail.
Ability to manage multiple tasks and deadlines effectively.
Experience preparing and presenting formal presentations.
Strong interpersonal skills, including the ability to work with providers and medical office staff.
Ability to work in a cross-functional, highly matrixed organization.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs.

Nice To Haves

Contract negotiation experience.

Responsibilities

Oversee the plan’s provider relations function, team members, and daily department operations, including provider education, outreach, and inquiry resolution.
Develop health plan-specific provider relations strategies, identifying specialties and geographic locations to focus resources and establish sufficient, cost-effective, high-quality provider networks and long-term partnerships.
Collaborate with health plan network management and operations teams and business stakeholders on provider services functions and strategic initiatives, including standards, resources, tools, and sharing best practices.
Develop and deploy strategic network planning tools to guide provider services and contracting strategy across the organization.
Facilitate planning and documentation of network management standards and processes across all lines of business.
Provide matrix team support for new-market provider and contract support, issue resolution, and national contract management.
Build or facilitate provider communication, training, and education programs for internal staff, external providers, and other stakeholders.
Ensure compliance with company and plan business requirements, state and federal statutes, government-sponsored program requirements, and network access standards.
Oversee provider representative activities, including developing or presenting policies, procedures, training materials, and reports.
Support ongoing provider network development and educate contracted providers about plan procedures and claims payment policies.
Develop and implement tracking tools to ensure timely issue resolution and compliance with applicable provider relations standards.
Oversee timely interventions and communications when providers raise issues or complaints, including claims and encounter data, eligibility, reimbursement, and provider website concerns.
Support plan initiatives and help ensure regulatory requirements and strategic goals are met.
Ensure cross-departmental communication about provider relations initiatives and contracted provider issues.
Design and implement programs to build and nurture positive relationships among contracted providers, ancillary providers, hospital facilities, and the plan.
Develop and implement strategies to increase provider engagement in HEDIS and quality initiatives.
Engage contracted providers on cost control initiatives, medical cost ratio, non-emergent utilization, and CAHPS to positively influence future trends.
Develop and implement strategies to reduce member access grievances with contracted providers.
Oversee the integrated health home program and ensure alignment with department requirements, provider education, and oversight.
Hire, train, manage, and evaluate team members; provide coaching, development, and recognition; maintain appropriate staff training and regular team meetings; and promote communication and collaboration.