Provider Network Optimization Lead

Humana

6d•Remote

About The Position

Become a part of our caring community and help us put health first The Lead, Provider Network Optimization role manages the strategic development and maintenance of South Carolina (SC) Medicaid and Dual Special Needs Plan’s provider network. This experienced strategist is responsible for driving network optimization and value, while also ensuring compliance with network requirements in the SC Managed Care Contract. This Lead role will analyze provider network performance to inform contracting and terminations, partner with the Provider Relations/Engagement team to understand and address network operational issues, and advise on network composition, and value-based payment strategy. This is a collaborative role requiring critical thinking and problem-solving skills, independence, leadership, a strategic mindset, and attention to detail. This position reports to the plan’s Chief Operating Officer. Preference will be given to applicants located in South Carolina.

Requirements

Bachelor’s Degree
Travel to Columbia SC on a quarterly basis
4+ years’ experience working with a managed care organization or as a consultant in a network/contract management role, such as contracting, provider services, etc.
2+ years of experience in provider network development, including contracting, network operations, and/or network maintenance
2+ years of experience in value-based contracting models
2+ years of experience in data analysis
Proficiency with a wide range of physician/facility/ancillary contract reimbursement methodologies
Prior leadership and management experience
Ability to manage multiple priorities in a fast-paced environment
Experience working in a matrixed organization and influencing change and direction
Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

Master’s Degree
Resides in South Carolina
Proficiency with analytic tools such as PowerBI, Quest or similar
Experience with the SC Medicare/Medicaid/government healthcare programs and contracts, and advocate for network priorities with internal stakeholders and shared services

Responsibilities

Define & execute network development strategy that promotes access, adequacy, and drives high value care delivery in alignment with financial, operational and clinical goals.
Maintain annual and ad hoc updates to network development plan Subject Matter Expert (SME) on SC contractual requirement for network standards and penalties for noncompliance.
Identify areas of risk with Network Adequacy reporting and strategize network time & distance, provider-to-enrollee ratio, and/or timely access gap closures by targeting providers for recruitment to Humana network and monitoring progress.
Subject Matter Expert (SME) on provider crosswalk/mapping from Humana’s data to state file and ensure accuracy on data submissions to the state agency.
Oversee ad hoc contracting/re-contracting campaigns for new or expanded services.
Collaborate with clinical and utilization management (UM) to identify access to care issues that include timely access standards, geographic barriers, close panel limitations, operational issues (i.e.: Problems with claims payment, staffing, rates), and member-specific barriers.
Manage network assessment and build for value-added benefit and in-lieu of services.
Root cause load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory.
Relay to appropriate department to address issue.
Ensure required submissions to state agency for incurable gaps and terminations.
Monitor terminations to account for termination impact and adequacy fluctuations.
Oversee required communication processes to notify members & providers.
Develop tracking system for transparency.
Set strategy and identify providers for participation in value-based payment (VBP) programs for SC according to contract requirements.
Lead routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals; manage approvals for non-standard FFS or VBP rate requests.
Identify trend-bender opportunities through contract renegotiation and VBP.
Provides market oversight and governance of the management of SC value-based payment models.
Monitor performance against key performance indicators (KPIs) and ensure compliance with contractual commitments and requirements.
Partner with health plan leadership to improve KPI performance and ensure contractual compliance.
Participates in operating meetings, as needed, for key provider relationships to facilitate strategic initiatives and improved performance.
Works collaboratively with Chief Operating Officer, Provider Services Director, health plan finance, corporate Network Operations, clinical and quality teams to achieve strategic goals and priorities.