VP, Health Plan Provider Network (Must reside in Nevada)

Must reside in the state of Nevada.

About the Role

Provides executive strategy and leadership to the Provider Network Department. Supports staff and senior management to develop and implement provider contracting strategies and provider service strategies to contain unit cost, improve member access, improve provider performance, and enhance provider satisfaction. 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.

Responsibilities

• Develops and implements provider network and contract strategies, including evaluation of existing networks as well as expansion and new markets. Strategies will consider network adequacy, membership profile/needs, provider quality and efficiency, product pricing, and competitor network composition.
• Supports the national network and actuarial teams to inform the annual PADU reimbursement guidelines and process. Monitors and offers recommendations in exception analysis.
• Drives expansion of value-based contracting, including stars, quality, clinical, population health, and other metrics.
• Directs network-related communication among segment, health plans, and national network team.
• Collaborates with health plan network teams to contract providers in accordance with segment strategy. Monitors and reports against plan and adequacy standards.
• Leads the network strategy and provides parameters for risk-sharing contract structure, payment models, and performance incentive models to support achievement of cost and quality goals in concert with established company templates and guidelines with physicians, hospitals, and other healthcare providers.
• Oversees all delegation oversight, provider services, and provider/member problem prevention, and provides oversight of the provider/member appeals and grievance process.
• Collaborates with enterprise data teams to report on network efficiency, utilization, and quality. Identifies opportunities for improvements and coordinates with local market teams.
• Understands the impact of contract provisions on claims payment accuracy and timeliness and seeks to minimize unnecessary deviation to support auto-adjudication.
• Collaborates with the national network team on provider manual updates.
• Works across functions to support overall health plan strategy across Network, Quality, Population Health, Utilization Management, Care Management, and Community Engagement.
• Key member of the leadership team; supports segment strategy and execution.

Requirements

• At least 12 years of experience in healthcare to include experience in provider network management/contracting, healthcare operations, and/or government-sponsored programs, and at least 10 years of senior-level network experience, or equivalent combination of relevant education and experience.
• At least 7 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 healthcare provider compensation methodologies.
• Excellent negotiation and relationship-building capabilities.
• Demonstrated adaptability and flexibility to changes and response to new ideas and approaches.
• Superior interpretation and research skills to readily identify problems, get to the root cause, and achieve prompt issue/problem resolution.
• Ability to navigate complex regulatory environments.
• Data-driven decision-making skills and strong 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.

Preferred Qualifications

• Deep experience with Medicaid, Medicare, and Marketplace managed care plans.

Pay

Pay Range: $186,201 - $363,093 / ANNUAL. Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.