Manager, Network Programs (New York Health Plan - EST HOURS) at Molina Healthcare

Long Beach, California, United States -

Full Time

Start Date

Immediate

Expiry Date

05 Jun, 26

Salary

0.0

Posted On

07 Mar, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Network Programs Management, Provider Negotiations, Claim Resolution, Cost Containment, Operational Efficiency, Regulatory Compliance, Risk Mitigation, Quality Audits, Data Analysis, Process Improvement, Team Leadership, Out-of-Network Claims, Independent Dispute Resolution, Performance Metrics, Contract Management

Industry

Hospitals and Health Care

Description

Job Description Job Summary Leads and manages Team responsible for the performance and execution of New York Health Plan network initiatives and strategies to support network adequacy, financial performance, and operational efficiency. This position negotiates with complex and strategic providers, including but not limited to hospitals, Independent Physician Associations (IPAs), and behavioral health providers, to support timely claim resolution, cost containment, and sustainable provider relationships. Job Duties * Leads, mentors, and manages a team responsible for provider out-of-network (OON) claim negotiations, claim reviews, and Independent Dispute Resolution (IDR) cases, while also taking an active, hands-on role in negotiations and discussions. * Works with department leadership to establish clear performance expectations, goals, and KPIs to ensure SAIs and operational targets are met. * Oversees complex, high-dollar, or sensitive negotiations on escalated cases. * Works with department leadership to review and approve settlement recommendations to ensure alignment with industry-standard pricing, savings objectives, and organizational guidelines. * Ensures all negotiation activities comply with applicable state and federal regulations, contractual requirements, and internal policies to drive timely resolution. * Supports department leadership in working to ensure compliance is maintained and to identify, assess, and mitigate regulatory and negotiation-related risks. * Conducts quality audits of negotiation outcomes, documentation, and communications to ensure accuracy and consistency. * Tracks, analyzes, and reports on negotiation outcomes, savings performance, turnaround times, and emerging trends. * Works alongside department leadership to identify opportunities for process improvements, training enhancements, and optimization of negotiation tools and resources. * Collaborates with operations, analytics, and leadership teams to improve workflows and operational efficiency. * Supports the development, refinement, and implementation of negotiation playbooks and best practices while supporting strategies that reduce out-of-network utilization and provider billing issues. * Serves as a point of escalation for internal stakeholders and external partners regarding complex or unresolved negotiations. Job Qualifications REQUIRED QUALIFICATIONS: * At least 5 years experience contract-related experience in the health care field including, but not limited to, provider’s office, managed care organization, or other health insurance entities; at least3years’ experience in provider contract negotiations ideally in negotiating different provider contract types, i.e. physician, group and hospital contracting, etc, or equivalent combination of relevant education and experience * At least 1 year management/leadership experience. 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.

Responsibilities

This role leads and manages a team responsible for executing New York Health Plan network initiatives focusing on adequacy, financial performance, and efficiency, which includes hands-on negotiation with complex providers like hospitals and IPAs. Key duties involve overseeing out-of-network claim negotiations, ensuring regulatory compliance, tracking performance, and driving process improvements.