Network Optimization Principal

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The Principal, Network Optimization oversees the strategic development and maintenance of SC Medicaid and Dual Special Needs Plan’s provider network. This senior-level strategist is responsible for driving network optimization and value, while also ensuring compliance with network requirements in the SC Managed Care Contract. The Principal 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.

· 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 Medicaid NetAd 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

· Sets 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.

Use your skills to make an impact
 

Required Qualifications

Bachelor’s Degree

· 6+ 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

· 4+ 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

· The applicant must be located in or willing to relocate to SC– (if market has local Humana office) position may be based at our office in[city] or remote within the state.

Preferred Qualifications

Master’s Degree

· Experience with the SC Medicaid contract, including network adequacy requirements and standards for provider relations compliance

Work at Home Criteria  

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.  

  Interview Format  

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. Modern Hire 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.

Scheduled Weekly Hours

40

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.

 

$126,300 - $173,700 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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.

About us
 

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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Equal Opportunity Employer

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.