Health Plan Provider Contracts Manager - Complex

Provides subject matter expertise and leadership for health plan provider network complex contracting activities. Supports network strategy and development with respect to adequacy, financial performance, and operational performance.

Responsibilities

• Negotiates contracts and letters of agreement with the complex provider community to secure high quality, cost-effective, and marketable plan providers.
• Contracts/re-contracts with large-scale entities involving custom reimbursement; executes standardized alternative payment model (APM) contracts; issues escalations, and supports network adequacy, joint operating committees (JOCs), and delegation oversight.
• Executes, manages, and optimizes value-based contracts and enhanced provider relationship management.
• Directs analysis of financial impact of deal terms and prepares details and justification for executive approval for agreements outside of Molina approval guidelines.
• Negotiates complex provider contracts including high-priority physician group and facility contracts using preferred, acceptable, discouraged, unacceptable (PADU) guidelines (emphasis on number or percentage of membership in value-based relationship contracts).
• Develops and maintains provider contracts in contract management software.
• Targets and recruits additional providers to reduce member access grievances.
• Engages targeted contracted providers in renegotiation of rates and/or language; assists with cost-control strategies that positively impact the medical cost ratio (MCR) within each region.
• Advises network contracting team members on negotiation of individual provider and routine ancillary contracts.
• Maintains contractual relationships with significant/highly visible providers.
• Evaluates provider network and implements strategic plans with the goal of meeting Molina’s network adequacy standards.
• Assesses contract language for compliance with corporate standards and regulatory requirements and reviews revised language with assigned corporate attorney.
• Participates in fee schedule determinations including development of new reimbursement models; seeks input on new reimbursement models from corporate network leadership, legal, and senior-level engagement as required.
• Educates internal customers on provider contracts.
• Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital, and ancillary providers.
• Participates with the leadership team and other committees to address the strategic goals of the department and organization.
• Participates in contracting-related special projects as directed.
• Provides training, mentoring, and support to new and existing contracting team members.
• Travels regularly throughout designated regions to meet targeted needs.

Requirements

• At least 5 years of experience in network contracting with large specialty or multispecialty provider groups.
• At least 3 years of experience in provider contract negotiations in a managed health care setting, ideally negotiating different provider contract types (i.e., physician/group/hospital), or equivalent combination of relevant education and experience.
• Working familiarity 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.
• Negotiation and relationship-building capabilities.
• Ability to navigate complex regulatory environments.
• Data-driven decision-making skills and analytical abilities.
• 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.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office suite and applicable software programs.

Preferred Qualifications

• Contracting experience with integrated delivery systems, hospitals, and groups (specialty and ancillary).
• Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.

Pay

$83,252 - $163,931 / ANNUAL. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.