Director, Health Plan Provider Relations (Nebraska ...

JOB DESCRIPTION Leads and directs team responsible for health plan provider relations activities. Supports network development, network adequacy and provider training and education. Serves as primary point of contact between the business and contracted providers within the Molina network. Responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina policies and procedures. Collaborates with network leadership and the corporate network team to develop and implement standardized provider relationship management and provider services for the health plan. Essential Job Duties u2022 Oversees the planu2019s provider relations function and team members. Responsible for the daily operations of the department, including leading and supporting various provider relations activities including provider education, outreach and inquiry resolution. u2022 Develops health plan-specific provider relations strategies - identifying specialties and geographic locations to concentrate resources for the purposes of establishing a sufficient network of participating providers to serve the health care needs of the plan's members, and successfully develop and refine cost-effective and high quality strategic provider networks - ensuring establishment of both internal and external long-term partnerships. u2022 Collaborates with health plan network management and operations teams and functional business unit stakeholders to lead and/or support various provider services functions and strategic initiatives with an emphasis on developing and implementing standards, resources, tools and best practices sharing across the organization. u2022 Develops and deploys strategic network planning tools to drive provider services and contracting strategy across the organization. Facilitates planning and documentation of network management standards and processes for all line of business. u2022 Provides matrix team support including, but not limited to: new markets provider/contract support services, resolution support, and national contract management support services. u2022 Builds and/or facilitates provider communication, training and education programs for internal staff, external providers, and other stakeholders. u2022 Ensures compliance with applicable company/plan business requirements including state/federal statutes, government sponsored program requirements, and network access standards. u2022 Oversees and leads provider representatives activities, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards. u2022 Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claims payment policies. u2022 Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards related to provider relations. u2022 Oversees appropriate and timely interventions/communications when providers have issues or complaints (e.g., problems with claims and encounter data, eligibility, reimbursement, and provider website). u2022 Serves as a resource to support the planu2019s initiatives and helps to ensure regulatory requirements and strategic goals are realized. u2022 Ensures appropriate cross-departmental communication of provider relations initiatives and contracted network provider issues. u2022 Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and the plan. u2022 Develops and implements strategies to increase provider engagement in Healthcare Effectiveness Data Information Set (HEDIS) and quality initiatives. u2022 Engages contracted network providers regarding cost control initiatives, medical cost ratio (MCR), non-emergent utilization, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to positively influence future trends. u2022 Develops and implements strategies to reduce member access grievances with contracted providers. u2022 Oversees the integrated health home (IHH) program and ensures IHH program alignment with department requirements, provider education and oversight. u2022 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 u2022 At least 8 years of provider services experience, including experience supporting individual/group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid and Medicare products, or equivalent combination of relevant education and experience. u2022 At least 3 years of management/leadership experience. u2022 Strong understanding of the health care delivery system, including government-sponsored health plans. u2022 Experience with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including: fee-for service (FFS), capitation and various forms of risk, ASO, etc. u2022 Previous experience with community agencies and providers. u2022 Strong organizational skills and attention to detail. u2022 Ability to manage multiple tasks and deadlines effectively. u2022 Experience with preparing and presenting formal presentations. u2022 Strong interpersonal skills, including ability to interface with providers and medical office staff. u2022 Ability to work in a cross-functional highly matrixed organization. u2022 Excellent verbal and written communication skills. u2022 Microsoft Office suite and applicable software programs proficiency. Preferred Qualifications u2022 Contract negotiation experience. + Experience with Salesforce. + Strong Excel skills - reporting & analysis. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $92,434 - $172,732.18 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2026-02-19