Senior Representative, Health Plan Provider Relations - Remote Must reside in NE

Provides senior level support for health plan provider relations activities. Supports network development, network adequacy, and provider training and education. Serves as primary point of contact between the business and contracted providers within the Molina network. Responsible for network management including provider education, communication, satisfaction, issue intake, access/availability, and ensuring knowledge of and compliance with Molina policies and procedures.

Responsibilities

• Successfully engages the plan's highest priority, high-volume, and strategic complex community 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 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.
• Resolves complex provider issues that may cross departmental lines and involve senior leadership.
• 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 providers and staff to assess compliance with Molina policies/procedures or Centers for Medicare and Medicaid Services (CMS) guidelines/regulations, or to evaluate 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.
• Initiates, coordinates, and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians (e.g., 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 on behalf of the health plan; may also deliver training 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 through education and promotion of Molina initiatives (e.g., administrative cost-effectiveness, member satisfaction—Consumer Assessment of Healthcare Providers and Systems (CAHPS), regulatory-related programs, Molina quality programs, and electronic solutions such as electronic data interchange (EDI), EMR, provider portal, and provider website).
• Serves as a subject matter expert for the provider relations function and provides training and support to new and existing provider relations team members.
• Requires 80%+ same-day or overnight travel (extent depends on the specific health plan service area).

Requirements

• At least 3 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.
• Understanding of the health care delivery system, including government-sponsored health plans.
• Understanding of various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including fee-for-service (FFS), capitation, and various forms of risk, ASO, etc.
• Experience delivering training and facilitating educational presentations.
• 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.
• Proficiency in Microsoft Office suite and applicable software programs.

Qualifications

• Experience in provider services, operations, and/or contract negotiations in a Medicaid, Medicare, and/or Marketplace managed health care setting—ideally with different provider types (e.g., physician, group, hospital).

Pay

Pay Range: $47,433 - $97,362.61 per year. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.