United States onlyJob Summary
Leads and directs team responsible for health plan provider network contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Collaborates with senior leadership and the corporate network management team to develop and implement standardized provider contracts and contracting strategies. Also responsible for negotiating complex contracts that are strategically critical to plan success, including but not limited to: alternative payment models (APMs), value-based payment (VBP) contracts and capitated payments for hospitals, independent physician associations (IPAs), and complex behavioral health arrangements.
Essential Job Duties
• Oversees the plan’s provider contracting function; responsible for leading the daily operations of the department and collaborating with other operational departments and functional business unit stakeholders to lead or support various provider contracting functions.
• Leads negotiations of contracts with the complex provider community that result in high quality, cost-effective and marketable providers.
• Contracts/re-contracts with large scale entities involving custom reimbursement; executes standardized alternative payment model (APM) or value-based payment (VBP) contracts.
• Leads initiatives and activities issue escalations, network adequacy, and joint operating committees (JOCs).
• Manages and reports network adequacy for Medicare, Marketplace, and Medicaid services.
• In conjunction with network leadership, oversees the development of provider contracting strategies including VBP; includes identifying those specialties and geographic locations to concentrate resources for purposes of establishing a sufficient network of participating providers to serve the health care needs of members, in addition to identifying VBP provider targets to meet Molina goals.
• Leads the achievement of annual savings through re-contracting initiatives, and implements cost-control initiatives to positively influence the medical cost ratio (MCR) in each contracted region.
• Leads preparation and negotiations of provider contracts and oversees negotiation of contracts, including VBP, in alignment with established company guidelines for contracting with physicians, hospitals, and other health care providers.
• Utilizes standardized contract templates and VBP/pay-for-performance (P4P) strategies.
• Develops and maintains reimbursement tolerance parameters (across multiple specialties/ geographies); oversees the development of new reimbursement models in collaboration with senior leadership.
• Communicates new contracting strategies to corporate provider network leadership.
• Utilizes standardized systems to track contract negotiation activity on an ongoing basis.
• Participates on the senior leadership and other committees to address the strategic goals of the department and organization.
• Oversees the maintenance of all provider contract templates including VBP program templates; collaborates with legal and corporate network leadership to modify contract templates, and ensures compliance with all contractual and/or regulatory requirements.
• Manages the contracting relationships with area agencies and community partners to support and advance plan initiatives.
• Develops and implements contracting strategies to comply with state, federal, National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data Information Set (HEDIS) initiatives and regulations.
• 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.
Required Qualifications
• At least 8 years of experience in network contracting with large specialty or multispecialty provider groups, and at least 5 years' experience in provider contract negotiations in a managed health care setting ideally negotiating complex provider contract types and value-based payment (VBP) models (i.e. physician/group/hospital), or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: value-based payment (VBP), fee-for service (FFS), capitation and various forms of risk, etc.
• 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.
• Ability to manage multiple tasks and deadlines effectively.
• Excellent verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.
Preferred Qualifications
• Deep experience negotiating alternative payment models (APMs).
• Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.
- Master's degree highly preferred.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
