Representative, Health Plan Provider Relations (Wisconsin long-term services and supports (LTSS) Provider Quality

Molina Healthcare•Long Beach, CA

13d

About The Position

Position collaborates daily with LTSS providers to include Adult Family Homes, Assisted Livings, Adult Day Care Centers, Ancillary Providers, and Nursing Homes in review of potential concerns in quality-of-service delivery to MCW members. Ensures provider quality for My Choice Wisconsin programs; compliance with contracts and certifications; investigates provider quality concerns; mitigates risk; subject matter expert on provider policies and procedures. The position performs all tasks associated with the provider concern process for the department to include concern review, review as applicable to quality standards and contract compliance, maintenance of concerns, provider corrective action plans, timely and accurate responses and onsite provider visits when severe concerns are identified.

Requirements

At least 2 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.
General understanding of the health care delivery system, including government-sponsored health plans.
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.

Nice To Haves

Healthcare Quality Management, Provider Relations, ability to read and apply contract expectations, and Healthcare experience
Has worked in a supervisory role in a regulated healthcare long term residential care setting for 4 years or more.
Experience with Medicaid and Medicare managed care plans.
Experience with Behavior Support Plan (BSP).

Responsibilities

Direct involvement and working knowledge of Wisconsin Long Term Care/Residential Care regulations, residential quality, deep understanding of Regulatory/oversight entities in Wisconsin to include but not limited to DQA, DHS, APS, Ombudsman or related experience
Ability to maintain schedules, meet deadlines, and differentiate urgent work and adjust priorities for work tasks and manage multiple projects. Ability to think critically and apply previously learned problem solving skills in a repeatable manner and be solution-oriented in a fast-paced environment.
Successfully engages high-volume, high-visibility plan 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 non-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.
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.).
May provide training and support to new and existing provider relations team members as appropriate.
Role requires 60 percent +; same-day or overnight travel (extent of same-day or overnight travel will depend on the specific health plan service area).