Set strategic direction for and oversee key business functions, including provider relations and training, claims analysis and education, provider quality and value-based payment performance.
Builds and supports the development and growth of positive, long-term relationships with network providers, including but not limited to primary care providers, hospitals, rural health clinics, human services districts, federally qualified health centers, behavioral health providers, and long-term care providers and healthcare systems to maintain service support excellence and improve financial and quality performance within the contracted working relationship with the health plan.
Regularly review data, such as claims denial/rework data and trends, call center data, and provider performance data to monitor team performance and guide strategic improvements to provider relationships and performance.
Provides North Carolina market oversight and governance of provider audits, compliance, provider surveys, provider service and relations, credentialing, contract management systems, and practice transformation.
Ensure team’s compliance North Carolina’s Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.
Work closely with enterprise teams on claims processing, reporting, contracting/credentialing, network adequacy, provider dispute resolution issues, and provider performance tracking and tool enhancements.
Understand Humana’s interoperability capabilities, drive provider recruitment strategy and engage in provider recruitment calls.
Guide the Provider Services Advisor to plan and deliver regular and ad hoc provider communications and provider training and education strategy
Drive performance and develops operational policies and procedures to align with the provider services model and executes strategic initiatives within the provider network.
Conduct regular performance evaluation of employees and provide ongoing feedback and coaching as necessary to achieve service, quality, and production goals.
Identify and support professional development for direct and indirect reports to drive exceptional associate engagement and performance
Set and monitor team key performance indicators
Represent Humana at North Carolina Medicaid meetings
Participate in, and travel to if needed, key provider meetings and provider association meetings
8+ years in provider relationship management, provider education, provider issue resolution, and provider value-based performance improvement
2+ years of project leadership experience.
Working knowledge of managed care health plan and provider operations
Experience working with providers in North Carolina
Experience with data analysis, understanding, communicating, and reporting on operational trends and gaps.
Knowledge of Medicaid regulatory requirements.
Intermediate knowledge of Microsoft Suite applications, specifically Word, Excel, and PowerPoint.
Ability to travel throughout North Carolina
Experience with credentialing and contract management systems
Experience with North Carolina Medicaid managed care
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$138,900 - $191,000 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Originally posted on Himalayas
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