Senior Network Operations Professional - Remote in US

Profile

Description

The Provider NetworkSenior Network Operations Professional works with the Network Operations lead to oversee 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 oversee claims research and resolution processes. 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 the retention of the plan's network of providers, creating a qualified, serviceable and comprehensive network. This is a collaborative role requiring critical thinking skills, independence, leadership, a strategic mindset, and attention to detail.

Responsibilities

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 oversight into claims research and resolution processes.

Work closely with Data Management teams on claims processing, resolution issues, and provider performance tool enhancements.

Work closely with Product Teams to ensure new developments align with provider expectations.

Drives performance and executes on strategic initiatives within the provider network.

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 South Carolina Medicaid plan.

Required Qualifications

Bachelor's degree

3 or more years of provider contracting or physician network development experience

2 or more years of project leadership experience

Knowledge of Medicaid regulatory requirements

Intermediate knowledge of Microsoft Word, Excel and Access

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

Preferred Qualifications

Experience with credentialing and contract management systems preferred

Medical claims processing experience

Project management and process mapping experience

Work-At-Home Requirements

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information - How we Value You

Health/Vision/Dental Benefits Effective day one

Competitive pay/salary ranges

PTO

VTO day

Associate Incentive Plan

401K Match- Immediate company match of 125 percent on the first 6 percent of your pretax 401(k) or Roth 401(k) contributions.

Well-being program

Tuition Reimbursement

#LI-Remote

Scheduled Weekly Hours

40

Company info

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