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Molina Healthcare, Inc.

Director, Provider Network Management & Operations

Molina Healthcare, Inc. - Oak Brook, IL

Job DescriptionJob SummaryResponsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Maintains critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems and application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing.Knowledge/Skills/Abilities* Develops and implements Provider Network and Contract strategies, identifying those specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of participating Providers to serve the health care needs of the Plan's membership.* 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, collaborating with Molina Corporate and Legal departments. * Develops and maintains a system to track Contract Negotiation activity on an ongoing basis throughout the year; utilizes and oversees departmental training on the Emptoris contract management system.* Directs the preparation and negotiations of provider contracts and oversee negotiation of contracts in concert with established company templates and guidelines with physicians, hospitals, and other health care providers.* Contributes as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization.* Oversees the maintenance of all Provider contract information, Provider Contract Templates and assures that all contracts negotiated can be configured in the QNXT system. Works 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 Association(s) and Joint Operating Committee Management.* Provides accountability for Delegation Oversight function in the Plan.* Provides oversight of the Provider Network Administration area including: Provider Information Management (PIM) and business analyses of contracts and benefits to support accurate configuration for claims payment.* Oversees all Provider/Member problem prevention, research and resolution and provide oversight of the Provider/Member Appeals and Grievance process. * Coordinates with enrollment growth to ensure that Molina grows faster (profitable growth) than our competitors in key provider practices.Job QualificationsRequired EducationBachelor's Degree in a related field (Business Administration, etc.) or equivalent experienceRequired Experience* 7 - 10 years experience in Healthcare Administration, Managed Care, and/or Provider Services. * Experience managing/supervising employees.Preferred EducationMaster's DegreeTo all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.#CB-MHI

10 days 12 hours ago

Molina Healthcare, Inc.


Director, Provider Network Management & Operations Molina Healthcare, Inc. - Oak Brook, IL, United States


Location: Oak Brook, IL

Company Profile:
Molina Healthcare, a FORTUNE 500, multi-state health care organization, arranges for the delivery of health care services and offers health information management solutions to nearly five million individuals and families who receive their care through Medicaid, Medicare and other government-funded programs in fifteen states.