Network Operations Lead

Profile

Description

The Provider Network Operations Lead oversees the plan's strategic opportunity for growth, audit/survey analysis, action plan oversight, implementation and coordination, provider services and network development and required credentialing processes and coordination. They coordinate workforce development initiatives and work collaboratively with Humana business area leads, other contracted MCO's and the Department as prescribed. They maintain provider relations to support customer service activities through data integrity management and gathering of provider claims data needed for service operations. Responsible for the growth and retention of the plan's network of providers, creating a qualified and comprehensive network.

Responsibilities

Supports the development and growth of positive, long-term relationships with physicians, providers and healthcare systems in order to maintain and improve financial and quality performance within the contracted working relationship with the health plan

Provides market oversight and governance of provider audits, provider surveys, provider service and relations, credentialing, and contract management systems. Provides oversight and governance of the executed processes for intake and management of provider perceived service failures.

Provides market oversight and governance of the management of provider data for the health plan including but not limited to demographics, rates, and contract intent

Coordinates and collaborates with a matrix team of provider service and contracting representatives to ensure that Humana processes are aligned with State contract

and regulatory requirements. Ensures compliance with contractual requirements as it relates to the Market network and directs process improvement to address network non-compliance, market strategy and initiatives.

Dedicated Full time responsibility to the Kentucky Medicaid plan

Represents Humana Healthy Horizons in Kentucky Medicaid Health Plan as the Provider Network Director for all regulatory required meetings, audits and contract responsibilities.

Required Qualifications

Bachelor's degree

3 years of provider contracting or physician network development experience

Working knowledge in the areas of Practice Management, Long-Term Acute Care, home health, home infusion, behavioral health, ambulatory surgery, and the outpatient experience preferred

Experience with analyzing, understanding and communicating financial trends

2 years of project leadership experience

2 years of management experience

Knowledge of Medicaid regulatory requirements

Intermediate knowledge of Microsoft Word and Excel

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Experience with credentialing and contract management systems preferred

Preferred Qualifications

Experience with credentialing and contract management systems

Working knowledge in the areas of Group Practice Management, Long-Term Acute Care, home health, home infusion, behavioral health, ambulatory surgery, and the outpatient experience

Additional Information

This position will be located at the Humana Waterside facility but will temporarily be working remote in Kentucky.

Work at Home/Remote Requirements

Must ensure designated work area is free from distractions during work hours and virtual meetings

Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com