Negotiates agreements with highly visible providers who are strategic to the success of the Plan, including integrated delivery systems, hospitals and physician groups that result in high quality, cost effective and marketable providers.
• In conjunction with Director/Manager Provider Contracts, negotiates high priority physician group and facility contracts using Preferred, Acceptable, Discouraged, Unacceptable (PADU) guidelines.
• Develops and maintains provider contracts in EMPTORIS 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 Care Ratio (MCR) within each region.
• Maintains contractual relationships with significant/highly visible providers.
• Advises Network Provider Contract Coordinators and Specialists on negotiation of individual provider and routine ancillary contracts.
• Evaluates provider network and implement strategic plans with the goal of meeting Molina's network adequacy standards.
• Assesses contract language for compliance with Corporate standards and regulatory requirements and review revised language with assigned MHI attorney.
• Participates in fee schedule determinations including development of new reimbursement models. Seeks input on new reimbursement models from Corporate Network Management and legal.
• Educates internal customers on provider contracts.
• Participates on the management team and other committees addressing the strategic goals of the department and organization.
Bachelor's Degree in a healthcare related field or an equivalent combination of education and experience.