Senior Network Optimization Professional

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The Senior Network Optimization Professional drives network optimization and value and managing compliance with network requirements - including network adequacy - for Humana’s Michigan Medicare/Medicaid Integrated plan. The Senior Professional will support the analysis of provider network performance to inform contracting and terminations. They will work closely with the Provider Relations team to understand and address network operational issues. Additionally, they will advise on network composition and value-based payment strategy. This position works on problems of diverse scope and complexity ranging from moderate to substantial.

Key Role Objectives

• Contribute to executing strategy for Humana's Michigan Medicare/Medicaid Integrated plan provider network. This includes contracting approaches, unique partnerships, and deployment of value-based care models. The goal is to assure long-term, mutually successful provider relationships.
• Analyze internal and external data and market intelligence information.
• Monitor network adequacy data to recommend targeted contracting opportunities and support resolution process in the event of network terminations.
• Understand provider network strategic initiatives and their tactical execution, ensuring alignment to financial, operational and clinical goals.
• Support network governance meetings to proactively identify network issues, ensure compliance with Michigan Medicaid requirements, and support network operations.
• Monitor performance against key performance indicators and contractual commitments and requirements to ensure compliance. Work with Network Optimization Director to communicate updates on operational efficiencies and ideas on improving performance.
• Collaborate with clinical and utilization management (UM) to identify access to care issues.
• Lead network assessment and build for value-added benefit and in-lieu of services.
• Oversee ad hoc contracting/re-contracting campaigns for new or expanded services.
• Perform root cause research on load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory. Relay to appropriate department to address issue.
• Monitor terminations to account for impact and adequacy fluctuations ​and report terminations to state, as required by state contract.​
• Oversee required termination communication process to notify members and providers​.
• Monitor adherence to loading and credentialing requirements. ​
• Solve complex business challenges.
• Identify providers for participation in value-based payment (VBP) programs.
• Support routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals.
• Identify trend-bender opportunities through contract renegotiation and VBP.
• Works closely with internal partners to facilitate the creation of reporting and tools needed to meet regulatory requirements and to transition from an adequate to a fully optimized network.

Use your skills to make an impact

Required Qualifications

• Bachelor’s degree or five (5) years of experience working in managed care.
• Three (3) or more years of provider network contracting or provider data management experience.
• Two (2) or more years of process creation or improvement experience
• Proficient in MS Office Applications including SharePoint, Teams, MS Word, PowerPoint, Outlook, and Excel.
• Strong knowledge of provider network operations tools, processes, and best practices.
• Ability to manage and prioritize multiple projects.
• Proficiency at achieving results within a highly matrixed organization.
• This is a collaborative role requiring critical thinking and problem-solving skills, independence, tactical execution on strategy, and attention to detail.
• This role requires strong analytical skills and the ability to work effectively in a team-oriented environment.
• Ability to travel in Michigan.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher. 

Preferred Qualifications

• Master’s degree.
• Strong familiarity with Michigan Medicaid/government healthcare to actively advocate for Network Optimization’s network priorities with internal stakeholders and shared services.
• Proficiency in Microsoft Access.

Additional Information

• Workstyle: This is a remote position with minimal travel.
• Travel: Up to 10% travel occasionally to Humana’s Detroit office for team engagement and provider facing meetings in the state of Michigan.
• Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST).
• Medicaid Mileage Reimbursement: We provide mileage reimbursement for work-related travel. Eligible mileage includes Travel from your home to your first work location of the day, travel between client or assignment locations during the workday and travel from your final work location back to your home.

WAH Internet Statement

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 required; 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. HireVue 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.

Scheduled Weekly Hours

Pay Range

Description of Benefits

About us

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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.