Manager, Hospital Health Plan Provider Contracts (Florida)

Job Title

Leads and manages team responsible for Hospital Health Plan provider network contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Responsible for negotiating complex contracts that are strategically critical to plan 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.

Essential Job Duties

Oversees the plan's Hospital provider contracting function; collaborates with other operational departments and functional business unit stakeholders on various provider contracting activities. Negotiates contracts with the complex provider community that result in high quality, cost-effective and marketable providers. Contracts/re-contracts with large-scale entities involving custom reimbursement. Executes standardized alternative payment model (APM) or value-based payment (VBP) contracts. Issues escalations and supports network adequacy, joint operating committees (JOCs), and delegation oversight. In conjunction with contracting leadership, develops health plan-specific provider contracting strategies including VBP; includes identifying specialties and geographic locations to concentrate resources for the purpose of establishing a sufficient network of participating providers to serve the health care needs of the plan's members, in addition to identifying VBP provider targets to meet Molina goals. Assists in achieving annual savings through recontracting initiatives; implements cost-control initiatives to positively influence the medical cost ratio (MCR) in each contracted region. Prepares the provider contracts in concert with established company guidelines with physicians, hospitals, managed long-term services and supports (MLTSS) and other health care providers. Utilizes established reimbursement tolerance parameters (across multiple specialties/ geographies), and oversees the development of new reimbursement models. Oversees the maintenance of all provider and payer contract templates; collaborates with legal and corporate network management on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements. Ensures compliance with applicable provider panel and network capacity, adequacy requirements and guidelines; produces and monitors weekly/monthly reports to track and monitor compliance with network adequacy requirements. Develops and implements strategies to minimize the company's financial exposure; monitors and adjusts strategy implementation as needed to achieve desire goals and reduce minimize the company's financial exposure. Advises network provider contract 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 corporate attorney. Participates in fee schedule determinations including development of new reimbursement models; seeks input on new reimbursement models from corporate network management, legal and senior level engagement as required. Educates internal customers on provider contracts. Participates on the management team and other committees addressing the strategic goals of the department and organization. Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration.

Required Qualifications

At least 7 years of experience in network contracting with large specialty or multispecialty provider groups, and at least 4 years experience in provider contract negotiations in a managed health care setting ideally negotiating different provider contract types (i.e. physician/group/hospital), or equivalent combination of relevant education and experience. At least 1 year of management/leadership experience. Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: value-based payment (VBP), fee-for service (FFS), capitation and various forms of risk, etc. Strong negotiation and relationship building capabilities. Ability to navigate complex regulatory environments. Strong organizational skills and attention to detail. Data-driven decision-making skills, and analytical abilities. Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization. Strong ability to manage multiple tasks and deadlines effectively. Strong verbal and written communication skills. Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

Strong hospital contracting experience

Experience negotiating alternative payment models (APMs). Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.