Health Plan Provider Relations Manager (WI State ...

JOB DESCRIPTION Employee for this role must reside in Wisconsin Job Summary Provides subject matter expertise and leadership 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. The Manager is responsible for provider engagement, contract negotiation, issue resolution, and education while ensuring compliance with all applicable federal, state, and local regulations. Essential Job Duties u2022 Successfully engages the plan's highest priority, high-volume and strategic complex provider community providers (including value-based payment (VBP) and other alternative payment method (APM) contracts to ensure provider satisfaction, facilitate education on key Molina initiatives, and improve coordination and partnership between the health plan and contracted providers. u2022 Serves as the primary point of contact between Molina health plan and the for non-complex provider community that services Molina members, including but not limited to fee-for-service (FFS) and pay-for-performance (P4P) providers. u2022 Collaborates directly with the planu2019s external providers to educate, advocate and engage as valuable partners - ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service; effectively drives timely issue resolution, electronic medical record (EMR) connectivity, and provider portal adoption. u2022 Resolves complex provider issues that may cross departmental lines including contracting, finance, quality, operations, and may involve senior leadership. u2022 Conducts regular provider site visits within assigned region/service area; determines daily or weekly schedule, to meet or exceed the plan's monthly site visit goals. Proactively engages with the provider and staff to determine; for example, non-compliance with Molina policies/procedures or Centers for Medicare and Medicaid Services (CMS) guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members. u2022 Provides on-the-spot training and education as needed, including counseling providers diplomatically, while retaining a positive working relationship. u2022 Independently troubleshoots provider problems as they arise, and takes initiative in preventing and resolving issues between the provider and the plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters. u2022 Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians (examples include: issues related to utilization management, pharmacy, quality of care, and correct coding). u2022 Independently delivers training and presentations to assigned providers and their staff - answering questions that come up on behalf of the health plan; may also deliver training and presentations to larger groups, such as leaders and management of provider offices, including large multispecialty groups or health systems, executive level decision makers, association meetings, and joint operating committees (JOCs). u2022 Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives; examples of such initiatives include: administrative cost-effectiveness, member satisfaction - Consumer Assessment of Healthcare Providers and Systems (CAHPS), regulatory-related, Molina quality programs, and taking advantage of electronic solutions (electronic data interchange (EDI), EMR, provider portal, provider website, etc.). u2022 Oversees and demonstrates accountability for provider satisfaction survey results. u2022 Develops and deploys strategic network planning tools to drive provider relations and contracting strategy across the enterprise. u2022 Facilitates strategic planning and documentation of network management standards and processes (effectiveness is tied to financial and quality indicators). u2022 Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practice sharing across the organization. u2022 Navigates the matrix team environment including: new markets provider/contract support services, resolution support, and national contract management support services. u2022 Serves as a subject matter expert for the provider relations function. u2022 Provides training, mentoring, and support to new and existing provider relations team members. u2022 Role requires 10-20%+ same-day or overnight travel (extent of same-day or overnight travel will depend on the specific health plan service area). Required Qualifications u2022 At least 6 years of provider services experience, including experience supporting individual/group providers, hospitals, integrated delivery systems, and ancillary providers with Medicaid, Medicare, and or Marketplace products, or equivalent combination of relevant education and 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 Strong verbal and written communication skills. u2022 Microsoft Office suite and applicable software programs proficiency. Preferred Qualifications u2022 Management/leadership experience. u2022 Contract negotiation experience. u2022 Strong relationship management, negotiation, and problem-solving and issue resolution skills. u2022 Skilled in interpreting, drafting, and negotiating contract language and reimbursement structures. 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: $60,415 - $107,809 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2026-04-03