AVP, Provider Network Management & Operations (Idaho)

Molina Healthcare•Long Beach, CA

About The Position

Provides strategy and leadership to team responsible for network operations and contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Also responsible for negotiating complex contracts that are strategically critical to plan/product 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. Establishes and maintains a distinct high-performing and adequate network of compassionate and culturally sensitive providers aligned with Molina's mission, vision and values. Work Location - Idaho

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 - 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 strategy consistent with reimbursement tolerance parameters (across multiple specialties/geographies); oversees the development of new reimbursement models, and obtains input from corporate and legal on new reimbursement models.
Develops and maintains a system to track contract negotiation activity on an ongoing basis throughout the year; utilizes and oversees departmental training on the contract management system.
Directs the preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company templates and guidelines related to contracting with physicians, hospitals, and other health care providers.
Contributes as a key member of the senior leadership team and other committees; responsible to address the strategic goals of the department and organization.
Oversees the maintenance of all provider contract information, provider contract templates and ensure that all contracts negotiated can be configured in the QNXT system; collaborates with legal and corporate on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.
Oversees plan-specific fee schedule management.
Develops strategies to improve EDI/MASS rates.
Provides oversight of provider services and coordinates activities with provider associations and joint operating committee (JOC) leadership.
Provides accountability for the delegation oversight function in the plan.
Provides oversight of the provider network administration area including: provider information management and business analyses of contracts and benefits to support accurate configuration for claims payment.
Oversees all provider/member problem prevention, research and resolution, and provides oversight of the provider/member appeals and grievance process.
Coordinates with enrollment growth to ensure that Molina grows faster (profitable growth) than competitors in key provider practices.
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.