Senior Specialist, Provider Contracts HP

Job Title

Molina Health Plan Provider Network Contracting

Job Description

Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Responsible for contracting / re-contracting of standard deals, maintaining network adequacy, issue escalations and JOCs on exception. Able to execute standardized fee for service and other core payment method contracts with predefined, common programs. Typically does not entail heavy negotiations. Minimal ongoing engagement after contract. Synchronizes data among multiple claims systems when applicable, and the 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.

Job Duties

This role negotiates assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. Contracting / re-contracting of standard deals, maintaining network adequacy, issue escalations and Joint Operating Committees on exception.

• Initiates, negotiates, generates and tracks provider Letters of Agreement, contracts and amendments from initial draft to full execution utilizing approved standardized contract templates / amendments, including but not limited to Fee for Service and Alternative Payment Methods including Pay for Performance.
• Assists Manager and / or Director in the negotiation of medical group / IPA and hospital contracting.
• Identified as contract system lead by developing and maintaining provider contracts in contract management software.
• Supports network development throughout state to including researching, recruiting and negotiating with providers.
• Participates in the evaluation of provider network and implementation of strategic plans to meet Molina's network adequacy standards.
• Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital and ancillary providers.
• Assists in analysis and coordination of amendments, reimbursement, and language changes. Requests information of billing codes, services provided and other information needed to complete the contract profile.
• Coordinates preparation and routing distribution of documents to complete the contracting process in a timely and thorough manner according to standardized processes.
• Assists Manager and / or Director in the completion of Block Transfer Filings
• Communicates proactively with other departments in order to ensure effective and efficient business results.
• Trains and monitors newly hired Contract Specialist(s).
• Participates in other contracting related special projects as directed.
• Travels regularly throughout designated regions to meet targeted needs.

Job Qualifications

Required Education : Bachelor's Degree or equivalent work experience in health care field including, but not limited to, provider's office, managed care, or other health care field.

Required Experience / Knowledge, Skills & Abilities : 4-6 years previous experience in contracting with large specialty or multispecialty provider groups. 1-3 Years Managed Care experience

Preferred Experience : Knowledge of integrated delivery systems, hospitals and groups (specialty and ancillary) contracts highly desirable.

Preferred License, Certification, Association : Certified Recovery Peer Specialist certification required in the state of Florida