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

Molina Healthcare•Long Beach, CA

1d•Remote

About The Position

The Director, Health Plan Provider Relations leads the team responsible for provider relations activities for the New York Health Plan. The role supports network development, network adequacy, provider training, and education, and serves as the primary point of contact between the business and contracted providers in the Molina network. It manages provider education, communications, satisfaction, issue intake, access and availability, and provider compliance with Molina policies and procedures. The Director collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services across the health plan. The position oversees daily provider relations operations and team members, develops health plan-specific provider relations and network strategies, and supports provider services and strategic initiatives across business units. It leads network planning, provider communications and education, issue resolution, compliance with applicable requirements, and initiatives to improve provider engagement, quality, cost control, and member access. It also oversees the integrated health home program and manages team hiring, training, performance, coaching, and development.

Requirements

At least 8 years of provider services experience supporting individual or group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid, Medicare, 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, including fee-for-service, capitation, risk arrangements, 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 interface 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 suite and applicable software programs.

Nice To Haves

Contract negotiation experience.

Responsibilities

Oversee the 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 for network development and building sufficient, cost-effective, high-quality provider networks and long-term partnerships.
Collaborate with network management, operations, and other business stakeholders on provider services functions and strategic initiatives, including standards, resources, tools, and best-practice sharing.
Develop and deploy strategic network planning tools and facilitate planning and documentation of network management standards and processes across lines of business.
Provide matrix-team support for new-market provider and contract services, issue resolution, and national contract management.
Build or facilitate provider communication, training, and education programs for internal staff, providers, and other stakeholders.
Ensure compliance with company and health plan requirements, state and federal statutes, government-sponsored program requirements, and network access standards.
Lead 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 support timely issue resolution and compliance with provider relations standards.
Oversee timely interventions and communications addressing provider issues or complaints, including claims, encounter data, eligibility, reimbursement, and provider website issues.
Support health 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 with contracted providers, ancillary providers, hospital facilities, and the plan.
Develop strategies to increase provider engagement in HEDIS and quality initiatives.
Engage providers on cost control initiatives, medical cost ratio, non-emergent utilization, and CAHPS to positively influence trends.
Develop and implement strategies to reduce member access grievances involving contracted providers.
Oversee the integrated health home program and ensure alignment with departmental requirements, provider education, and oversight.
Hire, train, manage, and evaluate team members; provide coaching, development, and recognition; ensure staff training; and promote communication and collaboration through regular team meetings.