Director Provider Services Medicaid

Profile

Description

Humana Healthy Horizons in Indiana is seeking a Director, Provider Services (Director, Provider Engagement) who will lead a team that is accountable for growing positive, long-term relationships with network providers in order to foster positive provider experiences, accurate and timely provider claims submissions, and high-quality care delivery among network providers leading to improved financial and quality performance. They will oversee a team of direct and indirect reports responsible for provider relations and training, claims education, provider engagement and practice transformation. The Director, Provider Services (Director, Provider Engagement) will be responsible for setting strategic direction for Humana Healthy Horizons in Indiana provider services department, representing the team at state and/or key provider group meeting, ensuring that all provider services functions meets contractual requirements and ensuring state reports are completed timely and accurately. The Director, Provider Services (Director, Provider Engagement), requires an in-depth understanding of how organization capabilities interrelate across the team, Indiana Medicaid market, and the enterprise. This is a dynamic role requiring strong leadership experience, critical thinking/problem solving skills, and a strategic mindset.

Responsibilities

Sets strategic direction for and oversee key business functions, including provider relations and training, claims analysis and education, provider quality and value-based payment performance, and practice transformation.

Develops operational policies and procedures to align with the provider services model and executes on strategic initiatives within the provider network.

Enables the development and growth of positive, long-term relationships with physicians, key provider group, LTSS/HCBS, non-hospital facilities, Rural Health Clinics, behavioral health providers, FQHCs and other healthcare systems to foster provider retention and improve financial and quality performance within the contracted working relationship with the health plan.

Provides Indiana market oversight and governance of provider audits, provider surveys, provider service and relations, and provider feedback.

Regularly reviews reports provider complaints data and trends, claims denials/rework data and trends, provider training and communications, and provider performance data to monitor team performance and guide strategic Improvements where needed.

Represents the provider services team at all state meetings and regularly meets with key providers, as well as provider associations.

Ensures team's compliance with Indiana's Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.

Sets and monitors team key performance indicators (KPIs) and strategic goals.

Work closely with enterprise teams on provider call center, claims processing, reporting, contracting/credentialing, network adequacy, provider dispute resolution issues, and provider performance tracking and tool enhancements.

Works closely with the Provider Services Advisor to plan and execute upon regular and ad hoc provider communications and strategy for provider training and education.

Conducts regular performance evaluation of employees and provide ongoing feedback and coaching as necessary to achieve service, quality, and production goals.

Identifies and supports professional development for their team to drive exceptional associate engagement and performance.

Required Qualifications

Must reside in the state of Indiana or willing to relocate there within 3 - 6months of hire.

Must be able to travel in-state and willingness to commute to Indianapolis, IN on a weekly basis for leadership and state meetings.

Bachelor's degree in Business, Healthcare, Communications, or related field.

8 or more years of relevant experience, including but not limited to provider relations, provider education and training, and/or provider performance improvement, preferably with a Medicaid managed care plan.

5 or more years of progressive leadership and management experience.

Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers).

Knowledgeable of facility licensure and Indiana Health Care Provider enrollment for Indiana providers.

Experience with data analysis, understanding, communicating, and reporting on operational trends and gaps.

Knowledge of Medicaid regulatory requirements.

Comprehensive knowledge of all Microsoft Office applications.

This role is a part of Humana's Driver Safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.

Work at Home Requirements

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.

Humana will provide Home or Hybrid Home/Office associates 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.

Preferred Qualifications

Master's degree.

Experience in and/or understanding of Indiana Medicaid, provider landscape and networks.

Experience working with and/or in-depth knowledge of Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS) providers strongly preferred.

Proficiency in quality improvement processes, analyzing and interpreting financial trends.

Additional Information:

Workstyle: When hired, Remote with weekly travel into Indianapolis, IN with the possibility of transitioning to Hybrid Home after market implementation. Hybrid Home is considered working 1-2 days per week in the Humana Healthy Horizons office in Indiana and 3 - 4 days working remotely.

Travel: Up to 15% travel in the state of Indiana to meet with the state agency and to Humana office locations.

Direct Reports: Up to 5 associates.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

Social Security Task

Alert: Humana values personal identity protection. Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

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