Provider Optimization Professional

Profile

Job Information

Humana

Provider Optimization Professional

in

Lancaster

South Carolina

Description

The Provider Optimization Professional is responsible for day-to-day back-end relationships and serves as liaison with network contractors, provider relations, clinical/quality team, contract management and shared services. Will ensure prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues to improve financial and quality performance. The Provider Optimization Professional collaborates with the Provider Communications/Provider Education/Provider Relations/Engagement teams to ensure prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims. Additionally, the Provider Optimization Professional manage claims operations that involve member contact, investigation, and settlement of claims for and against the organization, and carry out Humana's proactive approach to minimize claims denials through education and training. The Provider Optimization Professional represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation, coding, and HEDIS performance. Will also be responsible for project managing special projects/initiatives, system configuration and trend tracking/monitoring. The individual in this role must exercise independent judgement and work under minimal supervision.

Responsibilities

Key Role Objectives

Functions as a project manager for provider issue resolution

Identifies problems, provide solutions, and resolves promptly based on complaints, changes in contract language, reporting and trending

Ensures prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues, as well as appropriate education about participation in Humana's South Carolina Medicaid plan

Proactively monitors all claim and network operational trends and remediation

Executes on Humana's South Carolina provider network development strategies to ensure a sufficient network for meeting the health care needs of Humana's South Carolina Medicaid plan members.

Assists with provider data validation efforts

Develops strategic project plan and implements appropriate actions related to all access and availability surveys

Market representative for reviewing all provider documentation (i.e., P&P's, Provider Manuals, Provider Resource Guide, Provider Billing Guide, etc.)

Assists with development and deployment of the quarterly Provider Newsletter

Creates and monitors process for tracking of network compliance (i.e., required provider trainings)

Key decision maker on network optimization meetings (i.e., PCP attribution, member disenrollment, etc.)

Coordinates channels of communication between Humana and its network providers/Liaison between network shared services (i.e., credentialing) and providers

Gather PCMH and hospital incentive information for service fund

Works with internal corporate partners to ensure cross-department communication and resolution of provider's issues.

Responsible for scheduling and leading collaborative meetings with clinical, quality, community engagement, and provider/member experience teams

Coordinates with Provider Call Center/Grievance & Appeals Department to review data, trends, and address provider issues

Coordinates with Quality Department on provider support related to quality metrics, integration of care and opportunities for practice improvements

Develops and implements operational policies and procedures to optimize the provider network

Identifies critical issues, presents and proposes resolution for review and implements interventions

Represents the scope of health plan/provider relationships across areas such as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS/STARS performance and operational improvements

Works with internal resources and systems (i.e., claims, reimbursement, provider enrollment) to provide the Perfect Experience in all provider interactions with Humana's South Carolina Medicaid plan, remembering that the goal is always one call resolution

Ensures compliance with South Carolina's managed care contractual requirements for provider relations, such as claims dispute resolution within specified timeframes

Manages confidential client information with discretion and good judgment in accordance with Company policies

Required Qualifications ​

4 or more years of progressive experience in managed care operations and provider relations

Experience working with or in health care administration setting

Exceptional relationship management skills

Excellent written and verbal communication skills

Proficient in analyzing, understanding, and communicating complex issues

Thorough understanding of managed care contracts, including contract language and reimbursement

Exceptional time management and ability to manage multiple priorities in a fast-paced environment

Knowledge of Microsoft Office applications

Proficient in analyzing and interpreting financial trends for health care costs, administrative expenses, and quality/bonus performance

Preferred Qualifications

Bachelor's Degree

Experience with South Carolina Medicaid

Experience working with facilities and ancillary providers, and/or FQHCs is strongly desired

Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution

Additional Information

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates 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

Associates 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 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

COVID 19 Vaccine

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

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 an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn't missed)

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 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.

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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