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The Senior Provider Engagement Professional is responsible for day-to-day front line relationship management for network providers in Humana’s Healthy Horizons Medicaid through provider relationship management, including provider training, education, responding to provider inquiries, and resolving issues, disputes or complaints. The Provider Engagement Professionals work together to manage provider onboarding and completion of required training, and to ensure prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims. Additionally, Provider Engagement Professionals manage claims operations that involve provider 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 individual in this role must exercise independent judgement and work under minimal supervision.Key Role Objectives
- Function as the first point of contact for provider issue resolution
- Identifies problems, provides solutions and resolves promptly
- Serves as a liaison between Humana Healthy Horizons and the provider community
- Provides the highest level of customer service to current or prospective providers
- Attends all JOCs and related meetings for assigned region/providers as the main Humana Healthy Horizons liaison
- Develops and maintains provider relationships to optimize provider experience and satisfaction, including face to face visits with providers
- 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 Medicaid pla
- Communicates Humana’s policies and procedures and provider training/orientation materials
- Coordinates provider training and provider orientation sessions
- Responsible for planning and facilitating the contractual provider trainings on an annual basis
- Works with internal corporate partners to ensure cross-department communication and resolution of provider’s issues
- Works with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide the Perfect Experience in all provider interactions with Humana’s Medicaid plan, remembering that the goal is always one call resolution
- Ensures compliance with managed care contractual requirements for provider relations, such as claims dispute resolution within specified timeframes
- Manages confidential client information with discretion and good judgement in accordance with Company policies
Use your skills to make an impact
Required Qualifications
- Must reside in South Carolina
- Position is field-based in South Carolina and requires travel to provider practices
- 5+ years of Health care or managed care experience working with providers (e.g., Provider Relations, Provider Contracting, Claims Education, Quality Education)
- Proven planning, preparation and presenting skills, with established knowledge of managed care processes and reimbursement methodologies
- Demonstrated ability to manage multiple projects and meet deadlines
Preferred Qualifications
- Bachelor’s degree
- Experience with South Carolina Medicaid
- Understanding of claims system, adjudication, submission processes, coding and/or dispute resolution
- Understanding of managed care contracts, including contract language and reimbursement
- Comprehensive knowledge of Medicare policies, processes and procedures
Additional Information
Driving Statement
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.
Scheduled Weekly Hours
40Pay 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.$71,100 - $97,800 per yearThis 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.
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.
