Senior Network Optimization Professional

Humana • Chittenden, VT

4d • Remote

About The Position

The Senior Network Optimization Professional ensures Humana’s Michigan Medicare/Medicaid provider network meets compliance standards and delivers value. Responsibilities include analyzing network performance, supporting provider contracting decisions, collaborating to resolve operational issues, and advising on network strategy. This position reports to the Network Optimization Principal. The Senior Network Optimization Professional drives network optimization and value and managing compliance with network requirements - including network adequacy - for Humana’s Michigan Medicare/Medicaid Integrated plan. The Senior Professional will support the analysis of provider network performance to inform contracting and terminations. They will work closely with the Provider Relations team to understand and address network operational issues. Additionally, they will advise on network composition and value-based payment strategy. This position works on problems of diverse scope and complexity ranging from moderate to substantial. Key Role Objectives Contribute to executing strategy for Humana's Michigan Medicare/Medicaid Integrated plan provider network. This includes contracting approaches, unique partnerships, and deployment of value-based care models. The goal is to assure long-term, mutually successful provider relationships. Analyze internal and external data and market intelligence information. Monitor network adequacy data to recommend targeted contracting opportunities and support resolution process in the event of network terminations. Understand provider network strategic initiatives and their tactical execution, ensuring alignment to financial, operational and clinical goals. Support network governance meetings to proactively identify network issues, ensure compliance with Michigan Medicaid requirements, and support network operations. Monitor performance against key performance indicators and contractual commitments and requirements to ensure compliance. Work with Network Optimization Director to communicate updates on operational efficiencies and ideas on improving performance. Collaborate with clinical and utilization management (UM) to identify access to care issues. Lead network assessment and build for value-added benefit and in-lieu of services. Oversee ad hoc contracting/re-contracting campaigns for new or expanded services. Perform root cause research on load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory. Relay to appropriate department to address issue. Monitor terminations to account for impact and adequacy fluctuations and report terminations to state, as required by state contract. Oversee required termination communication process to notify members and providers. Monitor adherence to loading and credentialing requirements. Solve complex business challenges. Identify providers for participation in value-based payment (VBP) programs. Support routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals. Identify trend-bender opportunities through contract renegotiation and VBP. Works closely with internal partners to facilitate the creation of reporting and tools needed to meet regulatory requirements and to transition from an adequate to a fully optimized network.

Requirements

• Must reside in Michigan or be willing to relocate to Michigan.
• Bachelor’s degree or five (5) years of experience working in managed care.
• Three (3) or more years of provider network contracting or provider data management experience.
• Two (2) or more years of process creation or improvement experience
• Proficient in MS Office Applications including SharePoint, Teams, MS Word, PowerPoint, Outlook, and Excel.
• Strong knowledge of provider network operations tools, processes, and best practices.
• Ability to manage and prioritize multiple projects.
• Proficiency at achieving results within a highly matrixed organization.
• This is a collaborative role requiring critical thinking and problem-solving skills, independence, tactical execution on strategy, and attention to detail.
• This role requires strong analytical skills and the ability to work effectively in a team-oriented environment.
• Ability to travel in Michigan.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance.
• Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Nice To Haves

• Master’s degree.
• Strong familiarity with Michigan Medicaid/government healthcare to actively advocate for Network Optimization’s network priorities with internal stakeholders and shared services.
• Proficiency in Microsoft Access.

Responsibilities

• Contribute to executing strategy for Humana's Michigan Medicare/Medicaid Integrated plan provider network.
• Analyze internal and external data and market intelligence information.
• Monitor network adequacy data to recommend targeted contracting opportunities and support resolution process in the event of network terminations.
• Understand provider network strategic initiatives and their tactical execution, ensuring alignment to financial, operational and clinical goals.
• Support network governance meetings to proactively identify network issues, ensure compliance with Michigan Medicaid requirements, and support network operations.
• Monitor performance against key performance indicators and contractual commitments and requirements to ensure compliance.
• Work with Network Optimization Director to communicate updates on operational efficiencies and ideas on improving performance.
• Collaborate with clinical and utilization management (UM) to identify access to care issues.
• Lead network assessment and build for value-added benefit and in-lieu of services.
• Oversee ad hoc contracting/re-contracting campaigns for new or expanded services.
• Perform root cause research on load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory.
• Monitor terminations to account for impact and adequacy fluctuations and report terminations to state, as required by state contract.
• Oversee required termination communication process to notify members and providers.
• Monitor adherence to loading and credentialing requirements.
• Solve complex business challenges.
• Identify providers for participation in value-based payment (VBP) programs.
• Support routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals.
• Identify trend-bender opportunities through contract renegotiation and VBP.
• Works closely with internal partners to facilitate the creation of reporting and tools needed to meet regulatory requirements and to transition from an adequate to a fully optimized network.

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level